Predictable apical microsurgery

by Dr John J. Stropko, USA

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1 - Patient preparation

Surgery will never replace solid endodontic principles and should always be a last resort. Apical microsurgery consists of nine basic steps that must be completely performed in their proper order so we can achieve the desired result for our efforts.

The nine steps are as follows:
1. Instruments, supplies and equipment are ready.
2. Patient, doctor and assistants positioned ergonomically.
3. Anesthetic and hemostasis staging completed.
4. Incision and atraumatic flap elevation.
5. Atraumatic tissue retraction.
6. Access, root-end bevel (root-end resection, RER, and REB) and crypt management.
7. Root-end procedures: root-end preparation (REP).
8. Root-end fill (REF) techniques and materials.
9. Sutures, healing and post-op care.

Predictable microsurgery requires the use of an operating microscope (OM) and a team committed to operating at the highest level. The Six-Handed Team approach optimizes the instruments, equipment, techniques and materials that today’s level of technology presents for the benefit of all — especially the patient!
Dr Berman, an old retired general surgeon, and one of my senior-year dental school instructors, would begin each general surgery lecture by tapping the lectern with his pencil, and after getting our attention, he would say, “Treat the tissues with tender loving kindness and they will respond in a like manner.” I have heard those very words many times while performing apical microsurgery. It is truly a gentle technique when the steps are followed in the proper order.
Preparation of the patient for predictable apical microsurgery
A thorough past medical history and dental examination, using as many diagnostic aids as possible, is a requirement for a predictable microsurgical event. Being thorough can also avoid unfavorable experiences.
For example, if the patient, or the physician, states he or she is sensitive or allergic to epinephrine, to any degree, the author highly recommends that apical microsurgery not be performed. One of my golden rules of thumb is, “No epi, no surgery … Period!” If the doctor chooses to proceed with the microsurgical procedure, it will be exceptionally more difficult for both the doctor and the patient.
The technology that exists today presents us with so much more presurgical information than was available even a few years ago, and the recent advances should be included in the diagnostic process whenever possible. A good example of current technology is cone-beam computed tomography (CBCT). The radiological images we have been using for many years were the best we had, but were very limited. Now, CBCT enables the microsurgeon a view of all angles of areas of concern in the maxillofacial region and supplies much of what was missing in the field of dentistry.1
The preparation of the patient not only takes the patient into consideration, but also the entire surgical team. The microsurgical protocol we teach involves four people: the doctor (pilot), the scope assistant with the co-observer oculars for evacuation and retraction (co-pilot), the surgical assistant using the monitor as a visual reference (flight director) and the patient (first-class passenger).
The medical history and all necessary pre-medications are reviewed with the patient to be sure that the latter are taken at the appropriate times before the surgery appointment. The patient is also instructed to rinse with Peridex and take an anti-inflammatory (preferably 600 mg of Motrin, if no allergies are present) the night before and also on the morning of the surgery. At the time of the appointment and before the patient is seated, he or she is once again asked to rinse with Peridex. The dental chair should allow the patient to recline comfortably and even allow the patient to turn to one side or another. Small Tempur pillows placed beneath the patient’s neck, small of the back or knees, make a big difference when used.
After the patient is completely comfortable in the chair, he or she is coached on how to make slow and small movements of the head, if necessary during surgery. The patient is appropriately draped for the surgery. It is especially important to wrap a sterile surgical towel around the head and over the patient’s eyes for protection from the bright light of the microscope and any debris from the surgical procedure.
An important psychological point is being sure to not tell the patient he or she “can’t move”! To an already tense patient, saying “don’t move” would probably cause unnecessary apprehension, stress or panic. In more than 500 surgeries, I’ve only had one patient that didn’t hold nice and still during the procedure once he was relaxed and had profound anesthesia.
Now is the time for the surgical team to get comfortable with the position of the patient, the microscope, endoscope and associated equipment. Modern OMs have many features to enhance comfort and proficiency during their use. Accessories like beam splitters, inclinable optics, extenders, power focus and zoom, variable lighting and focal length, etc., all contribute to ease of use, ergonomics and proficiency for the entire surgical team. The mutual comfort of the patient, the surgical assistants and the doctor is of the utmost importance. The microsurgical technique may take an hour or more, so unnecessary movements or adjustments for comfort’s sake during the operation may cause considerable inconvenience.
The doctor’s surgical stool must have adjustable arms to allow the elbows to support the back and serve as a reference point, or fulcrum, if the doctor has to reach for an instrument during the procedure. Ideally, neither the doctor nor the scope assistant have to remove their eyes from the oculars of the OM during the entire operation. The task of directing the whole operation belongs to the second surgical assistant. The second surgical assistant is the choreographer for the procedures that take place with the OM. He or she is in a position to observe, coach and/or pass instruments to either the doctor or the scope assistant. The second surgical assistant can see the entire surgical environment and is the only one on the team that has an overview, to keep track of everyone’s needs. It is important that all possible surgical instruments are organized for ease of access during the operation.
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While the anesthesia is getting profound, this is a perfect time to modify the needles that will be placed into the tips of the Stropko Irrigators (www.stropko.com) for use during the surgery. The notched ends of 25 gauge Monoject Endodontic irrigating needles (SybronDental) are removed by bending with Howe Pliers and placed into the end of the Stropko Irrigators. One tip is used with an air/water syringe and the other tip is used on the dedicated “air-only” syringe (DCI). The endodontic irrigating needles are then bent in the same configuration as the ultrasonic tip that is being used for the root-end preparation. After the needle is bent, the ergonomics of the bend can be verified quickly and easily because the patient is in the proper position and so is the doctor.
Optimally, there are three Stropko Irrigators available for any surgical procedure: one three-way syringe fitted with a larger blue tip (SybronEndo) for more general flushing of the surgical area (we call it the “Big John”); another three-way syringe fitted with a modified 25-gauge needle for more precise cleaning and drying (“Little John”); and one with an “air-only” syringe, fitted with a modified 25-gauge needle, for precise and dependable drying of the specific area without worry of moisture contamination.
Also, because the lumen of the high-speed evacuator tips (Young’s Surgical) is small, be sure to have extra tips readily available if one should become clogged. A beaker of water should be available so the scope assistant can occasionally clear the evacuator system of blood and tissue debris from the evacuator tip.
After topical anesthetic is placed, local anesthesia is started using less than one carpule of warmed 2 per cent lidocaine containing 1:50,000 epinephrine. This small amount is done to anesthetize the injection sites that will be used next for the blocks and infiltrations. The 1:50,000 lidocaine is used prior to the 0.5 per cent bupivacaine (Marcaine) because the Marcaine tends to burn upon injection, whereas the lidocaine is much friendlier to the patient. This is then followed with one or two 1.8 cc carpules of warmed Marcaine for nerve blocks and/or infiltrations. All anesthetic is warmed and injected very slowly to avoid any unnecessary trauma to the tissue, which also creates much less discomfort for the patient.
After the completion of administering the local anesthetics, it is time to perform hemostasis staging using 2 per cent lidocaine containing 1:50,000 epinephrine. It has been shown that 2 per cent lidocaine containing 1:50,000 epinephrine produces more than a 50 per cent improvement in hemostasis compared to 2 per cent lidocaine containing 1:100,000 epinephrine.2
While keeping the bevel of the needle toward the bone and directed apically toward the root ends, small amounts of 2 per cent lidocaine 1:50,000 are slowly injected into the free gingival tissue in two or three sites to the buccal of each tooth (MB, B, DB), approximately 3 mm apical to the muco-gingival line. Slow injection of just a few drops of the anesthetic causes a slight “ballooning” and blanching of the tissue in the immediate area. This is an important step because it causes the muco-gingival line to become more pronounced, allowing the operator to have better vision, resulting in more accuracy with the following hemostasis injections.
As the anatomy of the tissue unfolds during the injections, the operator should begin visualizing and planning the incision. The amount and nature of the attached gingiva is an important consideration whether a full sulcular or a mucogingival (Leubke-Oshenbein) flap is used. In general, a full thickness, sulcular flap is routinely used unless esthetics is a concern and there is an adequate zone of attached gingiva present. To ensure optimum hemostasis, the lingual tissues should also be infiltrated.
If doing surgery on the posterior quadrant of the mandible, special attention should be given to the apical region of the mandibular second molar. On occasion, a small foramen, called the foramen coli, may be present. The foramen coli, if present, contains an ascending branch of the mylohyoid nerve. This added step, “lingual hemostasis staging,” can contribute to more profound anesthesia, enhance crypt management, and, as a result, contribute to a more predictable event with less stress for the entire team.
If the surgery is to be performed on the maxillary, the patient is instructed to close on approximately eight layers of sterile gauze, (four 2x2’s folded over once) for stability of the jaws and to keep any debris from inadvertently entering the oral cavity. A single piece of a sterile 2x2 is also gently placed distal of the tooth/teeth to be operated on. If the surgical procedure is on the mandible, especially when a full sulcular flap is used, the operator may want to make the incision with the mouth slightly open before placing the gauze.
In either case, with the aid of the OM and using a pre-filled 3 ml. syringe fitted with a 20-gauge needle, the entire surgical site is rinsed with Peridex to make sure the area is clean of debris and free of plaque before the incision is made. The surgical site is now ready for the next important step in the procedure: Flap design, the incision and atraumatic flap elevation.

References

1. Thomas SL, Angelopoulos C. Contemporary Dental and Maxillofacial Imaging, Dent Clin North Am 2008; 52: xi
2. Buckley JA, Ciancio SG, McMullen JA. Efficacy of epinephrine concentration in local anesthesia during periodontal surgery. J Periodontol 1984; 55: 653–57
3. Harrison JW, Jurosky KA. Wound healing in the tissue of the periodontium following periradicular surgery II. The dissectional wound. J Endod 1991; 17 (11): 544–52




2 - the incision and atraumatic flap elevation

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Using a disposable CK2 microsurgical blade (SybronEndo), the incision is made. With the smaller size of this blade, very accurate incisions can be made that have a cleaner cut than those of the much larger BP #15 or BP #15S blade. As the incision is being made, the operator needs to visualize the suturing process.
Sometimes just a small variation in the design of the incision can make a big difference in the ability to achieve easier and less traumatic closure of the surgical flap. In general, the surgeon is working with relatively healthy tissue and no attempt should be made to remove or alter the periodontium. This is especially applicable when making a full sulcular flap.
All flaps are full thickness and the incision must be complete, so there is no inadvertent tearing upon retraction of the flap. The split thickness flap is to be avoided as it is the most traumatic and healing is compromised. The periosteum does not survive the flap reflection procedure. It has been postulated that depolymerized periosteal collagen plays a role in rapid reattachment of the flapped tissues to cortical bone.1 In general, all flaps should be extended, at a minimum, to the mesial of the second tooth anterior to the apex of the root being surgerized.
The flap design differs depending on the integrity of the bone over the roots, the amount and nature of the attached gingival tissue, the anatomy of the jaw and the absence or presence of fixed dental appliances. Basically, there are two flap designs: triangular (one releasing incision) and rectangular (two releasing incisions). They are normally either a full sulcular flap, or a mucogingival flap, depending on the location and situation. In general, the longer the length of the flap, the easier it is to control, and it has no effect on the healing process.
 
The full sulcular flap: This design is routinely used in all posterior quadrants. The full sulcular flap should be used in the anterior if there is a thin zone of attached gingival tissue or there is a concern about the possibility of a dehiscence over the root of the tooth being operated on
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Fig. 1: The full sulcular flap

The incision is made through the gingival crest, following the curvature around the cervical of the teeth involved in the surgical area. The operator should attempt to incise the tissue through the crest of gingival to the osseous crest of bone, leaving the healthy gingival attachment intact. The advantage of the full sulcular flap is the ability of the operator to easily visualize the “emergence form” of the involved teeth.
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Fig. 2: The incision ideally preserves the healthy periodontal attachment.


The Leubke-Ochsenbein or Mucogingival Flap: This flap is used only when there is an adequate amount of attached gingival tissue present and the periodontal probing is within normal limits. The incision design should be scalloping in nature and generally follows the architecture of the teeth, which allows for easy repositioning upon completion of the apical microsurgical procedures
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Fig. 3: The Leubke-Ochsenbein Flap, or Mucogingival Flap, is used when cosmetics are a concern and there is an adequate zone of attached gingiva


The retraction of the flap must also be accomplished in a gentle and atraumatic manner. The most common cause of postoperative pain and swelling arises from impingement of the tissue during the retraction process. The surgeon has to constantly monitor the end of the retractor to make sure there is no inadvertent impingement on the flap. This is when the “scope assistant” is most helpful because he or she is observing the surgical site with a different set of eyes! An effective way to achieve atraumatic retraction is to prepare a groove in the cortical plate of the bone, well apical to the anticipated access to the root-end.
A surgical length #8 round bur, on a high speed Innovator handpiece (SybronEndo), is used to make the groove. A high-speed handpiece that has air escaping from the working end should never be used because of the danger of air embolism. The “groove” creates a definite place for the retractor instrument to seat into and is easily maintained in position, by either the doctor or the assistant, and eliminates the problem of inadvertently slipping during the surgery. Impingement of the tissue is also more predictably avoided by using a groove to hold the retractor.
Retraction can be accomplished using either the Carr or Rubinstein Retractors; however, there are many styles of retractors to choose from. The retractor is chosen that will best maintain clear visibility to the surgical area and is comfortable for the operator.
After the flap is retracted and if there is any tension on the flap, the vertical releasing incision can be extended, or an additional “releasing incision” at the opposite side of the flap can be considered. The releasing incision is usually very minimal, only 3–4 mm long, and many times does not require suturing
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Fig. 4: The Molt, or Ruddle elevators, are inserted into the vertical releasing incision to begin the atraumatic flap elevation

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Fig. 5: The most common cause of postoperative pain is tissue impingement by the retractor.

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Fig. 6: Rubenstein retractor placed into the prepared groove
It is imperative the operator keeps in mind there should be no tension or stretching of the tissues. One should not hesitate to extend or modify the incision to eliminate tension on the tissues. When there is tension, there is usually an opportunity for crushing or ischemia of the tissue and a resultant delay in the healing process. Generally speaking, the larger the flap, the easier it is to maintain atraumatically during the surgical procedure.
It is important the tissues and osseous surface must be kept as moist as possible during the entire procedure. This can be accomplished with a fine stream of water from the Stropko irrigator (www.stropko.com).
Dr Berman, an old retired general surgeon and one of my dental school instructors, would begin each surgery by saying, “Treat the tissues with tender loving kindness and they will respond in a like manner.” How many times I have heard those very words while performing apical microsurgery. Apical microsurgery can truly be a gentle technique.


3 - access and crypt management

If a step is omitted, or not done completely, the next step will be difficult, if not impossible, to do properly. The operation will develop into a stressful experience for the patient, the staff and the clinician with an end result not as desirable or predictable.
If all of the steps are completed as outlined, all procedures can be performed without stress, and a favorable post-operative result can be expected. I have completed hundreds of apical microsurgical operations and all results were the same with just a few exceptions. The technique is very gentle and predictable, if all of the steps are followed without compromise.
After the properly designed flap has been atraumatically reflected and retracted, the access preparation is ready to begin. Some important considerations are:

  • How much bone exists on the buccal aspect of the root undergoing surgery? If there is total dehiscence, guided tissue regeneration has to be considered. Ideally, there should be at least 3–4 mm of healthy, intact crestal buccal bone remaining after the access preparation is completed
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  • How much of the apex can be beveled or resected? Usually, there is an adequate amount of root length to work with. The shorter the root, the more conservative the operator will have to be when beveling, and the closer the bevel should be to 0 degrees so less removal of the root end is possible.

If an exceptionally long post is present, that is closer to the apical terminus than desired, not as much of the root end can be resected. Or, if the periodontal bone level is less than desired, a more conservative amount of apical root structure should be removed to preserve as much crown/root ratio as possible.
Fortunately, the operating microscope (OM), and/or the Endoscope (JedMed), allows the operator the luxury of being ultra-conservative when necessary.
The access to the root end is done most effectively with a high-speed handpiece that has no air exiting the working end
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The usual air-driven handpiece does have air at the working end and using it could result in an air embolism. It is important to use as much water coolant as vision will permit to maintain the moisture in the tissues. Using a fine stream of water from the Stropko Irrigator fitted with a 27-gauge needle, the scope assistant can keep the area moist and evacuate excess fluids at the same time. The initial access and apiection can be accomplished with just three surgical length burs: the Lindemann bone bur, a #6 round bur and an 1171 fissure bur
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There are basically two different ways to begin the access:
1. Estimate the amount of the apex to be resected and, with a Lindemann bone-cutting bur, remove the apex and prepare the access opening in one general step. If there is any portion of the apex remaining in the crypt, it is curretted out and the access is more or less complete.
2. A more accurate procedure is to estimate the location of the apex. Then, using a #6 surgical length, round bur, slowly and gently remove the bone overlying the buccal surface of the root. When the buccal surface of the apex is uncovered, bone is removed until the coronal limit of the crypt is established and the general outline of the apex is readily observed and can be apiected at this time. Often, especially with larger periapical involvement, the lesion can be curetted and the entire apex exposed. If the lesion is more palatal or lingual, the root apex may prevent the necessary access for curettage and will have to be partially beveled or resected as part of the access process.
A thorough curettage is important because it is the first stage of achieving hemostasis from within the crypt. In general, if all of the granulation tissue is removed, the amount of hemorrhage will be greatly reduced, the management of the crypt is easier to accomplish and good visibility can be restored. This technique takes more time but results in better visibility and the ability to be more precise with the initial apiection. The finished bevel will be discussed in detail later in the article.
In general, a biopsy should be performed on all tissue removed from the body. We are usually quite confident of the pathological diagnosis of the LEO, but my feeling is even if the odds are 1 in 100,000 that we are incorrect, no chances should be taken and a biopsy should be taken on a routine basis.
The final dimension of the access opening varies and is dependent on several factors
  • The size and position of the lesion. If the lesion is larger, the access will of necessity be larger in order to perform a complete curettage.
  • The position of the apex determines the size of the access. The more lingual the apex, the more overlying bone has to be removed and the larger the access has to be for good visibility.
  • The access has to be large enough to allow the instruments room to prepare the apical canal system without inhibiting their freedom of movement. The larger the instruments used, the larger the access must be.
  • The thickness of overlying bone is also important. If the buccal plate is thick, a wider access is necessary to eliminate a “tunnel effect” so vision is not compromised.
  • The experience and ability of the surgeon, and equipment available, is a great determinant on how large the access will need to be. I use both an Endoscope and the OM when performing apical microsurgery. On some occasions, the Endoscope permits a better view of the surgical site due to increased lighting and magnification. It also increases the ability to view previously difficult, and sometimes impossible, areas to see with the OM. The extent of a defect or existing anatomical variations that are lingual to the involved root end are typical examples of the value of also having an Endoscope during microsurgical procedures.
The management of the crypt is one of the most important steps, and the operator should take as much time as necessary to achieve the desired result. The clean and well-managed crypt is essential for good visibility and proper use of the retrofill materials. Ferric subsulfate (Monsels Solution, Cutrol), calcium sulfate (Capset, SurgiPlaster), Telfa pads and epinephrine-soaked pellets (Epidry from Pascal) are the most commonly used and effective agents for this purpose.
After all granulation tissue and other debris have been thoroughly removed from the crypt, hemostasis is often achieved as a result of proper “hemostasis staging injections” discussed previously. If that is the case, only an appropriately sized piece of Telfa pad lining the floor of the crypt is necessary to enhance lighting. However, this is not always the case and even slight bleeding must be addressed.
If the crypt exhibits slight hemorrhaging, the tissue surface or piece of Telfa trimmed to the correct size to fit can be lightly streaked with Monsels Solution and pressed into the floor of the crypt for a short period of time until the hemorrhaging is controlled
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If there is moderate hemorrhaging, the Monsels Solution is carefully applied with a micro applicator (Ultradent) directly to the problem area in the floor of the crypt. Keep in mind that only a small amount is necessary
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When ferric sulfate is used to achieve hemostasis, a thick brownish-black coagulum will usually result
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The resultant coagulum can be easily removed from the crypt with a clean Micro-applicator (Ultradent), gently flushed with water using a larger tip on a Stropko Irrigator as the assistant is evacuating any debris during irrigation of the crypt. The process is repeated until the bleeding is controlled. As soon as there is complete control of all bleeding in the crypt, the Telfa should be removed and replaced with a fresh piece so there is as much “white” surface as possible to facilitate light reflection and enhance vision.
As long as the coagulum resulting from the use of Monsels Solution has been cleaned out of the crypt after the completion of the surgery, its use has not been shown to affect the healing process.1
Caution: All forms of ferric sulfate must be kept well within the confines of the crypt. It has an extremely low pH and will instantly chemically cauterize anything it touches. The buccal plate of bone, the periosteum, soft tissue and the Scheniderian membrane should always be avoided! It is important to keep in mind that “If a little bit is good, a lot is not better!” Use only small amounts on the end of an applicator because a small amount goes a long way
Note: There are two popular forms of ferric sulfate: Monsels Solution has a concentration of 72 percent and Cutrol is 53 percent. I like the Monsels Solution because it is very effective, readily available and less costly to use.
On a few occasions, severe hemorrhaging occurs. This can be a result of inflammation, a severed interdental artery or a compromised clotting mechanism.
At any rate, when the blood flows faster than the evacuator can remove it, there is good reason for a little excitement and fast action! The first thing to do is to apply pressure over the crypt with a finger. This will stop the hemorrhaging long enough to calmly prepare the next few steps. In a low and controlled voice, instruct the assistant to insert a bigger tip into the evacuator and hold it close to the crypt. If after removing your finger, the hemorrhaging has not subsided, quickly replace your finger over the crypt as before.
It is a good idea at this time to take a radiograph and clinically re-evaluate the surgical area to make sure no unforeseen anatomical structures (mandibular canal, palatine artery, etc.) have been infringed upon.
Now have your assistant take a piece of sterile cotton roll and make a “cotton plug” large enough to completely fill the crypt, lightly streaking the tissue surface with Monsels Solution and insert into the crypt, holding it firmly in place with your finger for a minute of so.
After a few minutes, the cotton “plug” can be safely removed and you can proceed without undue concern. A gentle irrigation with the Stropko Irrigator will remove most of the dark-colored coagulum. The above technique has worked all three times I found myself in that situation. In two of my cases, an interdental artery was the cause and the other was highly inflamed granulation tissue remaining in the crypt.
If hemorrhaging occurs on the surface of the exposed buccal plate, a Touch and Heat (SybronEndo) can be used. The scope assistant can evacuate the “bleeder” with a small surgical tip, so its exact source can be determined, and the Touch and Heat can be used to effectively cauterize it. After the hemorrhaging is completely controlled and the crypt relatively cleansed of the coagulum, a fresh piece of Telfa should be placed over the internal surface of the crypt
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Keep in mind when using the OM that light and dryness are the most important factors for good visibility. Note: Never proceed to the next step until total crypt management has been accomplished.
Once the crypt management is completed, the clinician can proceed to refinement of the bevel and preparing the retropreps with confidence and good visibility. At the end of this step, all hemorrhaging should be controlled; the grossly resected apical end of the root should be easily seen; and the floor of the crypt should be covered with a clean, white piece of Telfa. An apical microsurgeon’s dream!

4 - the REB and REP

The amount, or degree, of the root-end bevel (REB) is of utmost importance and should be precisely planned in advance after considering the overall crown/root ratio, presence of posts or other obstacles, the root anatomy and the periodontal status of the tooth. According to previous research, 98 percent of canal system ramifications occur in the apical 3 mm.
If the bevel is long (traditionally 25 degrees to 45 degrees) an excessive amount of root structure would have to be removed to include the apical 3 mm on the palatal, or lingual, part of the root’s apical canal system (especially in roots with multi canals). If the bevel is closer to 0 degrees, the lingual 3 mm is easier to remove; more root structure can be conserved, improving the crown/root ratio. With a long bevel, there is also an increased risk of completely missing some important palatal or lingual anatomy, especially if the operator is in any measure trying to be conservative in order to preserve as much crown/root ratio as possible
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The long bevel creates a spatial problem that is generally impossible for the operator to overcome while trying to visualize the true long axis of the canal system
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The longer the bevel, the greater the tendency is for the operator to leave more of the palatal, or lingual, aspect of the root intact. Because it is difficult to visualize the long axis of the tooth, the resultant retroprep is not as likely to be within the long axis of the canal.
This concept is of utmost importance and is the primary reason that, on occasion, the retroprep unintentionally perforates to the lingual or palatal
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Another important consideration is, with a bevel as close to 0 degrees as possible, the cavo-surface marginal dimensions (bet you haven’t heard that term in awhile!) of the root end preparation will be considerably decreased. Therefore, the restoration will be easier to place and have less chance of leakage.
The root anatomy is especially important when there are more than two canals in one root. This occurs most commonly in maxillary bicuspids and in the mesial roots of nearly all molars. It has been shown that as many as 93 percent of the MB roots of the max. First molars have a second (MB2) canal.2 However, the operator has to be constantly aware that multiple canals can occur in any root, no matter what tooth is being operated on. If there is an isthmus present, it can usually be seen with the OM if the root has been adequately beveled and stained with methylene blue.
The refinement of the bevel is best accomplished with a surgical length 1171 carbide-tapered fissure bur (Brassler) in a 45-degree handpiece (SybronDental). These handpieces have no air exiting from the working end, which nearly eliminates the possibility of an air emphysema, or air embolism, beneath the flap.
A standard high-speed handpiece should never be used for the above reason. On occasion, the refinement of the bevel can cause additional bleeding due to some enlargement of the crypt. The operator should address any newly created crypt management problem before proceeding any further. Remember that it is of utmost importance to fully complete one step before proceeding to another!
After the REB is refined and crypt management is completely under control, the apical surface is rinsed and dried with a Stropko Irrigator (www.stropko.com). The clean and dried surface is then stained with methylene blue. It is important to allow the methylene blue to remain on the tooth for just a short period of time before gently rinsing and drying again to enable inspection of the stained surface.
Normally, a fresh, white piece of Telfa is reinserted for better lighting. If there are any fractures, presence of isthmus tissue or accessories present, the staining will greatly enhance the operator’s ability to visualize them. Also, the methylene blue will stain the periodontal ligament and enable the operator to be sure the apex has been completely resected.
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If there is an accessory canal present, the easiest answer is usually to bevel past it and restain. Or, on occasion, the accessory can be “troughed out,” leaving the bevel as is.
When two canals are present in the same root, it is necessary to prepare for an isthmus between the two canals even if the staining didn’t reveal one. It has been shown that in the mesiobuccal roots of the maxillary first molars with two canals, the 4 mm section displayed a partial or complete isthmus 100 percent of the time.3 This combined with the finding in the same root in maxillary molars, that two canals present clinically at least 93 percent of the time in the mesiobuccal root of the maxillary first molar, lends importance to always prepare isthmus area of the REB.2
Although staining doesn’t always reveal the presence of an isthmus, it may lie just below the surface, only to be exposed during the remodeling process of the surface of the beveled root that normally takes place during the healing process.
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The rule is to always prepare an isthmus when there are two canals in one root.
The preparation of the root-end preparation (REP) is best accomplished using ultrasonics. There are many different ultrasonic units available. For the most part, they are all dependable and have a good service record. There are multitudes of ultrasonic tips to choose from. The newer diamond coated and vented tips (ProUltra Tips from DENTSPLY Tulsa Dental or KIS Tips from Obtura/Spartan) are much more efficient and especially good at removing gutta percha.
The most important consideration is not the brand of the ultrasonic unit or type of tip but how the instrument is used. The tendency for the new operator is to use the ultrasonic in the same manner (pressure-wise) as the handpiece. The secret is to start at a low power setting and use an extremely light touch! The lighter the touch, the more efficient the action of the tip will be.
The correct amount of coolant is also important. If too much spray is used, visibility and cutting efficiency are both decreased. If too little spray is used, the necessary amount of cooling will not be available and overheating and/or micro cracks can be the result.
The occasional left and right, variously angled tips are necessary on occasion, but in most cases, the anterior type tips will suffice. If the canal is large and/or filled with gutta percha, a larger, coated tip can be used most efficiently. The key is to: 1.) slow down; 2.) be gentle; 3.) use a light, brushing movement; and 4.) carefully regulate the power setting of the ultrasonic unit. The power setting will vary greatly depending on the tip being used and nature of the preparation task at hand.
For the preparation of an isthmus, an uncoated, fine pointed tip (CT-1 by SybronEndo) is inserted into the ultrasonic and used to create a precise series of multiple “dots” on the stained or “imaginary” line between the two canals. For the DOT Technique, the ultrasonic unit is set at a low power setting but inactivated, water spray is turned off, a CT-1 tip is placed exactly where desired and the rheostat is “tapped” for just an instant. The process is repeated again, and again, as many times as necessary, until there are a series of “dots” (Fig. 6a). Then, while the water spray is still off, the dots are gently connected to create the initial, shallow but precise “tracking groove
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The DOT Technique is of great value, especially when there is concavity present and the width of the beveled root is very thin mesial to distal. The resultant groove serves as a definite guide for the completion of the isthmus portion of the REP. Then with the water spray turned back on and the power increased slightly, a pointed, coated tip can be used more aggressively to deepen the tracking groove. In this manner, accuracy is completely controlled and there is no chance of “slipping off” while preparing the isthmus in a very thin root. On occasion, if the walls of the prep become too thin, further beveling may be necessary.
Occasionally throughout the REP process, it is important to use the Stropko Irrigator to rinse and dry the REP to be sure it is kept within the long axis of the canals and all debris is being removed as planned. Various sizes of micro-mirrors, or an Endoscope, are used to periodically inspect the preparation and confirm accuracy.
A pre-cut and pre-bent 25 gauge endodontic irrigating needle (Monoject) works well for this purpose. The notched end is removed by rapidly bending the end one-third back-and-forth with a Howe Pliers. The needle inserted into the Stropko Irrigator is then bent similar to the ultrasonic tip to be used for the REP
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Always keep in mind that cleanliness and dryness are essential for good visibility when using the OM.
Of particular interest is the buccal aspect of the internal wall of the REP. Dr. Rubinstein was the first to point out that often this area is not debrided due to the angulation of the ultrasonic tip within the canal system during the REP. If there is some gutta percha “streaming up” the side of the wall, and the preparation is finished, the best thing is to take a small plugger and fold the gutta percha coronally so the wall is clean once more. It is usually futile to try to “chase after” the gutta percha with an ultrasonic tip.
The ideal REP should be: 1.) within the long axis of the canal system, 2.) have parallel walls, 3.) be at least 3 mm in depth (including the isthmus portion of the preparation), 4.) adequately extended to include any buccal/lingual variations of the canal system, 5.) be clean (free of a smear layer) and 6.) dry and ready to accept any type root-end filling material.
After completion of the REP, it should be rinsed and dried once more with the Stropko Irrigator. The REP is re-inspected, using micro-mirrors and the varying powers of the OM and/or Endoscope, to be sure it is clean and within the long axis of the canal system. At this time, the REP is etched with blue 35 percent phosphoric acid gel (Ultra-Etch by Ultradent) to remove the smear layer. After 15-20 seconds, the REP is thoroughly rinsed and dried with the Stropko Irrigator and re-examined with the OM.
If all is as desired, a 15-second rinse with 2 percent chlorhexidine will help eliminate any residual organisms present. One more gentle rinsing and drying with the Stropko Irrigator and the REP is ready for the root-end fill (REF).


5 -  REF materials, technique
In Parts 1 through 4, the necessary steps and procedures were presented, enabling the operator to atraumatically and predictably allow the root-end preparation (REP) to be sealed using any accepted root-end fill (REF) material. The surgical crypt should be clean and dry so vision is clear and unobstructed. Remember, the steps must be followed completely in order to achieve as predictable a result as humanly possible.
If, for some reason, crypt management is not complete, or the REP is not clean and finished, it is required to “go back” and repeat a step, or two, to achieve the desired result. The importance of having total control at this point in the apical microsurgical procedure cannot be over-emphasized.
The operator is now at a stage in the microsurgical procedure where the tissues have been atraumatically retracted, the crypt is well-managed and the acid etched; rinsed and dried REP is ready to fill. Removing the smear layer barrier, exposing the organic component (collagen fibrils) of the resected cementum and dentin, has been shown to enhance cementogenesis and is one of the keys to dentoalveolar healing.1
There are several materials that are currently available as a retrofill: amalgam, IRM, Super EBA “SEBA” (Bosworth, USA), bonded composites Optibond (SybronDental, United States), glass ionomers, such as Geristore (Den-Mat, United States) and more recently, Mineral Trioxide Aggregate “MTA” (Dentsply/Tulsa Dental Intl).
The number of publications in literature about research on the above materials is extensive, so only a few of them will be mentioned due to space. The author doesn’t want to recommend or condemn any retrofill material (except amalgam), but will generalize and relate his and others’ experience with them and opinions about their applications.
Amalgam and IRM were used for many years as the only commonly available retrofill materials. However, in almost every “leakage” study published during the past few years, amalgam has proven to be the worst offender, exhibiting the most leakage.2, 3 This fact, accompanied by the general controversy about mercury in amalgam, strongly suggests that there is no valid reason to continue its use as a retrofill material. The only real advantage to amalgam is the favorable radiopacit
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Since the advent of the anatomically correct, ultrasonic REP, one of the most popular and still-used REF material is Super EBA (SEBA). A recent follow-up study demonstrated a success rate of 91.5 percent using SEBA.4 The author used SEBA routinely in the early 1990s with full confidence of its sealing capabilities.
To some, the major drawback of SEBA is its technique sensitivity. The surgical assistant had to mix it until it was thick enough to roll into a thin tapered point with a dough-like consistency. For even a well-trained assistant, this was often the most stressful part of the microsurgical procedure. The “dough-like” tapered end of the thin SEBA “roll” was then segmented with an instrument, such as a small Hollenbeck Carver.
The small cone-shaped endpiece was then inserted into the retroprep and gently compacted coronally with the appropriate plugger. Two to five of these small segments were usually necessary to slightly overfill the retroprep.
Another problem experienced by many was that SEBA was unpredictable as to its setting time — sometimes setting too quickly and, at other times, taking much too long for the tired surgeon.
At any rate, after the REF is complete, an instrument, and/or bur, is used to smooth the resected surface, producing the final finish. A mild etchant is then used to remove the “smear layer” produced during the final finishing process. SEBA has a radiopacity comparable to that of gutta-percha, so it was necessary to educate the new referring doctor that a retrofill had indeed been performed
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However, in some recent studies, SEBA has been shown to have a better sealing ability that IRM, but not as well as MTA.
Bonding, using composite retrofill materials, is now completely possible due to having total control over the apical environment utilizing good crypt management procedures. Many different materials are available for use as a REF. Optibond (SybronDental) and Geristore (Den-Mat) are popular because of their ease of use. They both have good flowability, dual-cure properties and the ability to be bonded to dentine. Geristore is supported by research demonstrating biocompatibility to the surrounding tissues
The usual etching, conditioning of the dentin, insertion of the selected material, and curing by chemical or light is accomplished in a routine manner when bonding into the retroprep. (Note: Because the light source for the OM is so intense, it is mandatory to obtain an orange filter to use while placing the composite to prevent a premature set.) For most microscopes, an orange filter is available that easily and inexpensively replaces the “blood filter.” After the composite is completely cured, the material is finished with a high-speed finishing bur and the resected root end is etched with a 35 percent blue gel etchant (Ultradent, United States) for about 12 seconds to remove the “smear layer” and to demineralize the surface.
Several studies showed no leakage with bonding techniques and many operators use it as their technique of choice.
However, there is some controversy as to whether the resected surface of the root should also be coated with a thin layer of the bonding material. A “cap” of material (usually Optibond) was placed with the intention of sealing the exposed tubules on the resected surface.
The operators who cover the resected surface believe it necessary to ensure a good seal and the predictability would be better. On the other hand, there are also operators who do not believe the exposed tubules are a factor concerning the predictability of the healing process. They reason that nothing would heal as well, or be more biocompatible, than the exposed dentin of the apically resected surface.
The author did not cover the exposed apical surface and is convinced the jury is still out on this issue!
More recently, another material has become very popular and is widely used by many. Mineral Trioxide Aggregate (MTA) has attracted many converts. There is so much research that has been done, and so many publications presented, that just one reference would be futile.
The evidence extolling the virtues of MTA, regarding its sealing capabilities and its biocompatibility with the surrounding tissues, is overwhelming. The author has talked to many respected endodontists, and most are now using MTA as their routine retrofill material. MTA is chemically similar to calcium sulfate, forgiving to work with, and has a radiopacity slightly better than gutta-percha
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The main advantage of MTA is its ease of use, much like handling “Portland Cement.” One of the secrets to using MTA is to keep it dry enough so it doesn’t flow too readily (like wet sand), but yet is moist enough to permit manipulation and maintain a workable consistency.
The desired “thickness” is easily accomplished by using dry cotton pellets, or the MTA mix can be gently dried with a dedicated, air-only Stropko Irrigator (www.stropko.com). If the MTA is too dry and needs moisture added, that, too, is easily done with a cotton pellet saturated with sterile water. Properly mixed MTA can be extruded in pellets of various sizes (depending on the size of the carrier used) using a Dovgan Carrier (Quality Aspirators) and condensed with an appropriate plugger.
More recently, a simple method for delivery of the MTA into the REP was introduced
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The Lee MTA Pellet Forming Block has several differently sized grooves to create the desired aliquot of MTA. The MTA adheres to the instrument, allowing for easy and efficient placement into the REP
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For a denser and stronger consistency, the assistant can touch the non-working end of the plugger, or explorer, with an ultrasonic tip during the condensation process. The flow is increased and a much denser fill is achieved. As a result, “ultrasonic densification” also increases the radiodensity of the MTA’s appearance in the post-op radiograph, but it is still similar to gutta-percha
MTA has approximately an hour of working time, which is more than adequate for apical microsurgery and takes much “time pressure” out of the surgical procedure. Finishing the MTA is simply a matter of carving away the excess material to the level of the resected root end
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The moisture necessary for the final set is derived from the blood, which fills the crypt after surgery. The MTA is very hydrophilic and depends on moisture for the final set, so it is imperative that there is enough bleeding re-established after crypt management to ensure the crypt is filled. If any material, such as ferric sulfate, has been used for crypt management, it must be judiciously removed to restore blood supply to the crypt.
This can be considered the final step in “crypt management” and is especially important when MTA is used for the REF. If the size of the lesion indicates the use of guided bone regeneration, good blood supply is indicated anyway, so allow the blood to cover the MTA before placing the GBR material of choice. In a large lesion, it is sometimes difficult, even after curettage, to restore bleeding into the crypt (perhaps the crypt management was a little too effective), and it may be necessary to use a small round bur in the surgical handpiece to make several small holes in the surface of the crypt to aid in the re-establishment of the desired flow of blood.
Based on current studies, the operator can choose any one of the above mentioned REF materials and be comfortable that, if the proper protocol is followed, the apical seal will be predictable and healing uneventful.
References 1. Craig KR, Harrison JW. Wound healing following demineralization of resected root ends in periradicular surgery. J Endod 1993 Jul; 19(7): 339-47. 2. Martell B, Chandler NP. Electrical and dye leakage comparison of three root-end filling materials. Quintessence Int 2002 Jan; 33(1): 30-4. 3. Aqrabawi J. Sealing ability of amalgam, super EBA cement, and MTA when used as retrograde filling materials. Br Dent J 2000 Mar 11; 188(5): 266-8. 4. Rubinstein RA, Kim S. Long-term follow-up of cases considered healed one year after apical microsurgery. J Endod 2002 May; 28(5): 378-83. 5. Dragoo MR. Resin-ionomer and hybrid-ionomer cements: Part I. Comparison of three materials for the treatment of subgingival root lesions. Int J Periodontics Restorative Dent 1996 Dec; 16(6): 594-601

6 -  sutures, suturing techniques
All steps have been meticulously followed, the REF has been placed, the crypt has refilled nicely, the final radiograph has been approved, and it is time to suture the flap into position. Sadly, most operators now push the microscope aside and suture without it. To do this robs the operators of an opportunity to demonstrate to themselves and their patients the amazing capabilities of the OM.
The doctors must make a commitment to master the suturing technique using the OM.
It will never be accomplished with the OM pushed aside at this critical step in the apical microsurgical procedure. The following will be based largely on the author’s own experiences during nearly 20 years of doing, teaching and writing about apical microsurgery.
Dr. John Harrison has published some of the most clearly written and comprehensive work on wound healing associated with periapical surgery.
There are five publications that are a “must read” for the endodontic surgeon. These publications can be found in the Journal of Endodontics: 1991, Vol. 17, pp. 401-408, 425-435, 544-552; 1992, Vol. 18, pp. 76-81; and 1993, Vol. 19, pp. 339-347.
After reading these articles, the microsurgical protocol developed by Drs. Gary Carr, Richard Rubinstein and others becomes clearer and is more easily understood. The word “atraumatic” is an important factor to achieve predictable wound healing.
When the surgical site is ready for closure, the flap should be gently massaged to close approximation with the attached tissue. But, keep in mind, the flap has probably lost dimension, or “shrunk” slightly, due to the mere act of retraction over a period of time and has endured a slight decrease of blood flow to it. Fortunately, this is usually not a problem. If the initial incision was planned with this final step in mind, the tissues should re-approximate with minimal manipulation. Now is when the operator will appreciate nice “scalloping” and a sharp scalpel when making the incision in the beginning of the surgery
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Remember the old saying, “Hindsight is always 20/20”? The smooth side of a small #2 mouth mirror can be used to hold the tissue in position while the second surgical assistant (on the same side of the chair as the doctor) hands the doctor the needle holder with the needle positioned properly in the beaks so the sutures can be easily and accurately placed.
All suturing is accomplished using 6-0 black monofilament nylon (Supramid, S. Jackson). Some microsurgeons are using 8-0 and, even 10-0 sutures; but the 6-0 is easy to use, doesn’t tear through the tissue as readily and the results are no different than with the more technique-demanding, thinner sutures. Keep in mind, the sutures will be removed in 24 hours so it is really a moot point as to whether the suture is 6-0, 8-0 or 10-0.
The results achieved with 6-0 suture seem to be well suited to apical microsurgery. The black silk suture, traditionally used in surgery, is a detriment to the rapid healing we are trying to achieve. Not only does bacterial plaque more readily accumulate on it than monofilament but, also, the braiding acts as a wick for the migration of bacteria into the wound. This can result in an increased inflammatory response and compromised healing.
The type of needle used depends on the type of flap to be sutured. For the Oshenbein-Leubke Flap, a taper point needle (TPN), 3/8 circle (Supramid, S. Jackson, code MEA-60B) is used.
The TPN is far superior to the reverse cutting type needle (RCN) because there isn’t the tendency to cut, or tear, the flap edges. Also, the TPN require less effort to exit at a point in the attached tissue where the operator intends, not where the needle wants to exit.
In other words, it is easier to guide a TPN to the desired point of exit in the attached tissue than it is a RCN. They just seem to cooperate more when suturing this type of flap! One of the nicest things about using this flap design is the ability to easily see the healing taking place
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32

33

34

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For the Sulcular Flap, a reverse cutting needle (RCN), 3/8 circle (Supramid, S. Jackson, code MPR-60B) is used. This needle is used because the larger size facilitates passing it through the contacts when doing a sling suture. The sling, or mattress type, suture is routinely used to save time on closure, rather than doing individual buccal to lingual sutures. On many occasions, the TPN (see above paragraph) is also used to suture the attached gingival area of the flap at the coronal aspect of the releasing incision.
A technique for suturing using the SOM: While the scope assistant holds the retractor in place, the second assistant uses a small Castro-Viejo type needle holder. The beaks of the holder must grasp the needle approximately 3/4 of the distance from the pointed end to where the suture is attached to the needle. Special attention, by the second assistant, must be taken to keep the beaks of the holder away from either end of the needle, as these are the areas of the needle’s greatest weakness and can be inadvertently bent or broken
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Care is taken so the needle is firmly grasped perpendicular to the beaks of the holder. This allows the operator more definite control and a better “feel” of the needle during the suturing process.
The second assistant now passes the needle holder into the doctor’s normal working hand (Hand A). The doctor then begins the suturing process by inserting the needle through both sides of the incision. When the needle is completely through both sides of the incision, the needle is then grasped between the thumb and index finger of the opposite hand (Hand B).
While the doctor is doing this, the second assistant is holding the end of the suture so it won’t inadvertently be pulled through the tissues. The doctor proceeds to make the three loose “loops” around the beaks of the needle holder to start the first knot.
While the doctor is making these initial “loops,” the second surgical assistant is placing the end of the suture into the doctor’s visual field of the microscope, so the end of the suture can be easily grasped in the beaks of the needle holder by the doctor.
The second assistant can be sure the end of the suture is within the doctor’s field of vision by looking into a monitor that has been placed so it is easily seen
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The “loops” around the beaks of the needle holder create enough friction so there is a controllable tension between the doctor’s Hand B and the beaks of the needle holder in Hand A. Care must always be taken that the tension is only between Hand B and the needle holder in Hand A, so no undesirable tension is exerted on the tissue during the suturing process.
The purpose of maintaining some tension is to give the doctor a positive tactile sense while taking up the excess suture material in Hand B. As the suture is drawn through the tissue by Hand B, Hand A is lowered to prevent exerting too much tension on the tissue.
The tension on the suture is regulated by the looseness, or tightness, of the “loops” which control the amount of friction for the suture to overcome as it is gathered. Hand B continues gathering as Hand A yields the suture with a “descending” motion while still maintaining the desired tension, and the beaks of the holder have the end of the suture firmly secured.
When the end of the suture is at the desired length relative to the incision, the “loops” are allowed to slip off the beaks for the initial knot. Then, using the same basic rhythm of movements, the “securing” and “locking” knots are placed. It is an alternating rhythm of movement that is difficult to describe in writing, but is actually very easy for the beginning microsurgeon to learn.
The doctor now allows the second surgical assistant to take the needle holder from Hand A and simultaneously be handed the micro-scissors so the suture can be cut close to the knot.
After the second assistant takes the scissors and the suture, the doctor is handed a micro-forceps to gently move the knot between the point of insertion and the incision, helping to prevent plaque build-up over the incision itself
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Note: When moving the knot with the micro-forceps, it is important that the knot be “pushed” to place, not “pulled” to place. This ensures the suture’s original tension and integrity is maintained.
One of the most common mistakes made when suturing is to make the suture too tight. It is better to make the suture a little too loose than to make it too tight. When the suture is too tight, it causes ischemia and thus compromises rapid healing. When making a sling suture in a sulcular flap, it is easy to be too aggressive when tying the knot, causing the rest of the suture to get too tight. The doctor should always recheck the tension over the entire length of the suture before completing the securing knots.
The releasing incision is usually an integral part of every flap and is considered differently from the rest of the incision. Normally, the releasing incision is not sutured, but if it is, the suture should be looser than the other sutures. It has been shown that epithelial creep, or streaming, occurs rapidly, or at a rate of about 1 mm per side per 24 hours.
In other words, a wound whose edges were separated 2 mm would be expected to come together within a 24-hour period. In hundreds of surgeries during the past 12 years, there were only a few cases where the releasing incision wasn’t completely closed.
Of those few that didn’t close within 24 hours, they all closed within 48 hours. To repeat: If the operator prefers to suture the releasing incision, it must be sutured loosely
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Another consideration is to be sure to suture “like tissues to like tissues.” Never suture attached gingival tissue to unattached gingival tissue. If one side of the suture “tears out,” it will be the attached gingival side.
When using the OM to suture, the incision can be closed accurately with extremely good approximation. It is because of well-planned and nicely scalloped incisions; atraumatic flap elevation procedures; and the very close repositioning of the flap with thin, hair-like sutures (6-O) that we can plan on routinely removing sutures in 24 hours (see Figs. 6 and 7).
The sutures have completed their task after 24 hours, and in fact, have now become foreign bodies that can cause irritation, excessive inflammation, be a source of infection and, ultimately, result in a retardation of the healing process.6
For those who doubt the 24-hour Suture Removal Theory, an easy exercise is this:
  • At the next surgery, be sure to place at least five sutures.
  • After 24 hours, have the patient come in and remove the worst-looking suture, the one you think isn’t healing as well as the others.
  • Then, the next day, remove the next worst-looking suture.
  • The next day, do the same, and so on. At the end of the fifth day, the worst-looking suture will be the one remaining! If that doesn’t convince you, nothing will.
Post-operatively, the usual result is little, or no, pain or swelling. The post-operative instructions are ice packs 15 minutes on and then 15 minutes off for the first six hours only, gentle rinsing with Peridex for the next 24 hours, and have sutures removed the next day. Experience has demonstrated that prescribing Ibuprofen 600mg every six hours, along with 1-2 tabs of Tylenol OTC (taken between the doses of Ibuprofen), has a very effective anti-inflammatory effect.
It is the exception, rather than the rule, that a patient requires a stronger medication for post operative pain. Antibiotics are not usually prescribed.
If everything is within normal limits, the patient is instructed to begin gentle cleaning of the area on the third day post-op, using a wash cloth over his or her index finger, and to begin gentle brushing, with a soft brush, on day five. The patient is scheduled for a follow-up visit two weeks after surgery.
At the two-week visit, normally the incision is barely visible, and on most occasions, can hardly be detected.
A word of caution: Not all patients respond to treatment as well as others. Don’t be in a hurry to treat a problem that may not exist. On a few occasions, patients may be slower than normal in response to treatment, sometimes taking several weeks to heal as well as other patients have or do in just days.
If there is any doubt, place the patient on antibiotics and an anti-inflammatory for a week as a precaution, but what is really desired is more time for delayed healing to occur.
The apical microsurgical technique described in the previous six parts has become the standard of care in endodontic treatment and raises endodontic apical surgery to a new and exciting level.
For the first time, apical surgery can be performed with predictable results. But these results can only be achieved if the proper protocol is followed meticulously.
The steps must be followed without compromise. Much more could be written, but hopefully enough of an overview has been given to stimulate just one more doctor to begin using the OM. It is the finest tool our profession has ever been given.
Apical microsurgery can be an enjoyable part of the daily regimen, for both the doctor and the newly involved dental team!

References 1. Craig KR, Harrison JW. Wound healing following demineralization of resected root ends in periradicular surgery. J Endod 1993 Jul; 19(7): 339-47. 2. Martell B, Chandler NP. Electrical and dye leakage comparison of three root-end filling materials. Quintessence Int 2002 Jan; 33(1): 30-4. 3. Aqrabawi J. Sealing ability of amalgam, super EBA cement, and MTA when used as retrograde filling materials. Br Dent J 2000 Mar 11; 188(5): 266-8. 4. Rubinstein RA, Kim S. Long-term follow-up of cases considered healed one year after apical microsurgery. J Endod 2002 May; 28(5): 378-83. 5. Dragoo MR. Resin-ionomer and hybrid-ionomer cements: Part I. Comparison of three materials for the treatment of subgingival root lesions. Int J Periodontics Restorative Dent 1996 Dec; 16(6): 594-601. 6. Harrison JW, Gutmann JL. Surgical Endodontics. Blackwell Scientific Publications 1991; 278-331.
About the author
Dr. John J. Stropko received his DDS from Indiana University in 1964, and he practiced restorative dentistry for 24 years. In 1989, he received a certificate for endodontics from Boston University and recently retired from the private practice of endodontics in Scottsdale, Ariz.

Stropko is an internationally recognized authority on micro-
endodontics. He is the inventor of the Stropko Irrigator, has published in several journals and textbooks and is an internationally known speaker. He is the co-founder of Clinical Endodontic Seminars and and was an instructor of microsurgery for the endodontic courses presented at the Scottsdale Center for Dentistry. Stropko and his wife, Barbara, currently reside in Prescott,

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