Apicectomy

P R E S E N T E D B Y :
N E H A D E S H P A N D E
M D S I I
APICOECTOMY

CONTENTS
 Introduction
 Classification of Surgical
Endodontics
 Definition of Apicoectomy
 Indications and
contraindications
 Armamentarium (traditional
surgery and microsurgery)
 Surgical access: Soft and hard
tissue management
 Root-end resection
 Root-end preparation
 Root-end filling
 Wound closure and post-
surgical patient management
 Conclusion

INTRODUCTION
 There are multiple treatment planning options for root treated teeth that
develop recurrent periapical pathosis or have periapical lesions that fail to heal
following adequate root canal treatment.
 While nonsurgical revision is usually the clinical treatment of choice, many
teeth are unsuitable for revision owing to irreversible changes in the tooth or to
the nature of the periapical pathosis.
 Periapical surgery is not only appropriate for these cases but also for the
occasional case in which nonsurgical revision is possible but may result in
excessive destruction of either the tooth or restoration.
 In fact, data show that the success rate for surgical intervention may be higher
than that for nonsurgical revision and should be considered in the treatment-
planning process when teeth are compromised with failure of previous root
treatment.
 The choice of periapical surgery is a valid alternative to tooth extraction and
should always be considered.
Pitt Ford TR, Rhodes JS, Pitt Ford HE. Endodontics: problem-solving in clinical practice.

CLASSIFICATION
SURGICAL ENDODONTICS
I. PERIRADICULAR
SURGERY
A) Curettage
B) Root-end resection
C) Root-end preparation
II. FISTULATIVE
SURGERY
A) Incision & Drainage
B) Cortical Trephination
C) Decompression
III.
CORRECTIVE SURGERY
A) Perforation Repair :
1. Resorptive and carious
2. Mechanical
B) Periodontal management :
1. Root resection
2. Tooth resection
C) Intentional Replantation
Gutmann JL, Harrison JW. Surgical endodontics. Ishiyaku EuroAmerica; 1991.

SURGICAL ACCESS:
SOFT AND HARD TISSUE
MANAGEMENT

HEMOSTASIS
 Currently recommended maximum
dosage of epinephrine 1:50,000 in
local anesthetics 2% lidocaine for
adults for good hemostasis is 5.5
cartridges to reach 0.2 mg
 Because many anesthetics are
vasodilators the use of anesthetics
without vasoconstrictors, such as
plain mepivacaine (e.g. 3%
Carbocaine), is not recommended
as this will lead to excessive
bleeding during surgery

FERRIC SULFATEGELFOAM
SURGICEL
BONE WAX

 The first and most important step in achieving good
hemostasis is obtaining effective local anesthesia. If the
anesthesia is profound, achieving hemostasis during the
surgery is a simple task.
 The recommended steps are:
1. Administer the local anesthetic, using 2% lidocaine with 1:50
000 epinephrine.
2. Remove all granulation tissue as quickly and aggressively as
possible with frequent irrigation of the osteotomy site.
3. Use epinephrine pellets for additional hemostatic control in
the osteotomy.
4. Apply ferric sulfate if bleeding continues after the epinephrine
pellet technique

Soft tissue management...
Semilunar incision:
no longer
recommended because
of inadequate access
and scar formation
Removal of sutures is
done within 48 to 72
hours , not a week
New suture materials
are monofilament,
gauge 5-0 or 6-0 to
provide rapid healing
Papilla base incision
(PBI) has been developed
to prevent loss of
interdental papilla height
with sulcular incisions
Flap retraction during
the surgery is facilitated by
making a resting groove in
the bone, especially during
mandibular posterior
surgery, to ensure
retraction

CLASSIFICATION OF SURGICAL FLAPS
1. FULL MUCOPERIOSTEAL FLAPS
• Triangular (one vertical releasing incision)
• Rectangular (two vertical releasing incisions)
• Trapezoidal (broad-based rectangular)
• Horizontal (no vertical releasing incision)
• Papilla-base flap
2. LIMITED MUCOPERIOSTEAL FLAPS
• Submarginal curved (semilunar)
• Submarginal scalloped rectangular (Luebke-Ochsenbein)

DEFINITIONS
• The surgical removal of the apical portion of a root and
adherent soft tissues; may be performed in advance of root-
end preparation for a root-end filling or as a definitive
treatment.
ROOT-END
RESECTION
• A cavity created to receive a root-end filling during
periradicular surgery or intentional replantation; may be
accomplished using rotary or ultrasonic instrumentation
ROOT-END
PREPARATION
• A restorative material placed in the root-end preparation
during periradicular surgery or intentional replantation;
designed to enhance the seal of the root canal where
orthograde obturation has been less than optimal
ROOT-END
FILLING
Eleazer P, Glickman G, McClanahan S, Webb T, Jusrman B. Glossary of
endodontic terms. Editorial AAE: Chicago. 2012.

MICROSURGICAL INSTRUMENTS
EXAMINATION INSTRUMENTS
 Dental mirror and micromirrors, periodontal probe,
endodontic explorer, and microexplorer

 Microexplorer :
 It has a 2-mm tip bent at 90 degrees on
one end and 130 degrees on the other.
 The short tip makes it particularly easy to
maneuver inside the small bony crypt.
 This instrument is extremely useful for
locating an area of leakage on the
resected root surface and for
distinguishing a fracture line or canal
from an insignificant craze line

INCISION AND ELEVATION
INSTRUMENTS
 The ideal scalpel blade for
microsurgery is a 15C blade, which
is small enough to manage the
interproximal papilla but large
enough to make a vertical releasing
incision in one stroke
 Microblades are useful only when
the interproximal spaces are tight

 The soft tissue elevators are designed to
elevate the gingiva and tissue from the
underlying cortical bone with minimal trauma
to the tissue.
 One end of the instrument has a thin, sharp,
triangular beak and the other end has a sharp,
rounded beak that varies in size.
 Unlike the periosteal elevators used in
periodontics, this new design incorporates thin
edges and points that allow the soft tissue to be
elevated from the bone cleanly and completely.

 KimTrac retractors (B&L Biotech) have more variable widths than other
conventional retractors (from 8 mm to 14 mm compared with conventional
10 mm)
 KimTrac P1 and P2 retractors have wings to separate the elevated soft
tissue from the area of surgery and an additional plastic protector for soft
tissue elevation
 KimTrac can be used with and without a plastic protector.
 However, the plastic protector is advantageous as it ensures easy flap
retraction with highly improved visibility and accessibility to the operating
field. Unlike other products with blunt ends, the KimTrac is able to anchor
against the cortical boney plate precisely and stably, regardless of whether
the shapes are plain or protrusive, due to its serrated end.
 Comparison of the thickness of blades of retractors shows that the KimTrac
retractor is one-third the thickness of other retractors, making them an
ideal retractor using the bone grooving technique on mandibular posterior
surgery .

 The Kim/Pecora (KP 1, 2, and 3)
retractors (Obtura/Spartan) also have
wider tips than conventional retractors
(15 mm compared with 10 mm) and are
0.5 mm thinner. Their serrated ends
anchor the retractors securely on to the
bone.
 The KP 4 retractor is a small, all-
purpose retractor with the same
features as the others but has the
standard 10-mm width.

 The KP retractor tips are modelled to the concavities and convexities of the
cortical bony plate.
 Using an endodontic retractor on a convex or flat bone surface is difficult.
 The contact with the bone is limited to a very small area; in contrast, the
KP 1, KP 2, and KimTrac M5 retractors fit the convex contour of the bone.
 The full contact of the retractor tip on the bone provides a secure, stable
hold, eliminating sudden or creeping slippage that results in traumatized
tissue, swelling, and painful healing.
 It also eliminates interference and interruption during the surgery and
assistant fatigue.
 Many retractors are available on the dental market, but only the KimTrac
retractors and Kim/Pecora retractors are designed especially for
endodontic microsurgery.

ATRAUMATIC TISSUE RETRACTION AND THE
GROOVE TECHNIQUE
 One of the key factors in postoperative tissue swelling is because
of frequent slippage of the retractor during surgery
 This is also the main cause of transient parasthesia in the
mandibular molar/premolar region
 To address this problem, retractors of several shapes and sizes
were developed to permit stable and nontraumatic retraction.
These retractors have wider (15 mm) and thinner (0.5 mm)
serrated working ends compared to the standard retractors
 Some are concave while others are convex to accommodate the
irregular contours of the buccal plates.
 The serrated tips provide better anchorage on the bone and are
designed to prevent slippage during retraction..

GROOVE TECHNIQUE
 In addition to contour specific retractors, a new procedure has been developed
to protect the mandibular nerve and prevent postoperative problems, such
as parasthesia, when operating in the molar/premolar region near the mental
foramen.
 A 15-mm long horizontal groove is cut into the water-cooled bone with a
Lindemann bur or a #4 round bur.
 This groove must be made beyond the apex to allow space for the osteotomy
and subsequent apicoectomy.
 The groove permits secure anchoring of the serrated retractor tip and secure,
steady retraction of the flap.
 A safe and efficient way to make a groove above the mental foramen is to first
identify the foramen, then carefully cover it with the retractor and then make
the groove just above it. Once the retractor is in position within the groove,
there should be no movement or slippage

GROOVE TECHNIQUE
Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review. Journal of
Endodontics. 2006 Jul 1;32(7):601-23.

OSTEOTOMY INSTRUMENTS
A 45 degree surgical handpiece with a Lindemann bur is the
instrument of choice for this procedure (Brasseler NSK and Morita)
 It is designed to direct water on to the cutting surface by channeling it
along the surface of the bur while the air is ejected through the back of
the handpiece
 This reduces the chance of emphysema and pyemia and creates less
splatter than a conventional handpiece.
 The handpiece’s 45 degree angled head makes it easier to work in and
visualize difficult to reach areas.
 The Lindemann bone cutting bur is used for osteotomies and has fewer
flutes than conventional burs, resulting in less clogging and frictional
heat and more efficient cutting.

OSTEOTOMY
 An osteotomy should be just large enough to accommodate
the ultrasonic tip, but no larger than 4 mm in diameter.
 The use of CBCT is an important aid for determining the
location and size of the osteotomy.
 An osteotomy should be prepared at the lowest
magnification (e.g., ×4).

KEY HOLE
OSTEOTOMY
MODIFICATION

Bone Window Technique
 In cases where there is no
detectable buccal cortical plate
fenestration, or where a thick
cortical plate is expected, e.g.,
mandibular second molars, the
authors suggest a new technique,
which aims at preserving the
buccal cortical plate and promotes
faster healing.
 A piezo surgery device is used
(W&H Piezomed, Austria), which
resects osseous tissues with high
precision while the surrounding
soft tissue remains uninjured.

ROOT-END RESECTION
 The surgical removal of the apical portion of a
root and adherent soft tissues; may be performed
in advance of root-end preparation for a root-end
filling or as a definitive treatment.

ROOT-END RESECTION – RATIONALE
 Removal of pathologic processes
 Removal of anatomic variations
 Removal of operator errors in non-surgical treatment
 Enhanced removal of the soft tissue lesion
 Access to the canal system
 Evaluation of the apical seal
 Creation of an apical seal
 Reduction of fenestrated root apices
 Evaluation for aberrant canals and root fractures
Stropko JJ, Doyon GE, Gutmann JL. Root‐end management: resection, cavity preparation,
and material placement. Endodontic Topics. 2005 Jul 1;11(1):131-51.

ROOT-END RESECTION
ARMAMENTARIUM
 45 degree surgical handpiece:
NSK (Brasseler, USA)
 Morita Lindemann burs
 Microexcavators
 Methylene blue dye

Steep Bevel versus Shallow Bevel
 Usually a 45 degree angle bevel on a broad or oval-shaped root may
reveal the buccal canal (see cut level 1) whereas the lingual canal or
accessory canals emerging from the main canals to a lingual direction
may be missed. Ideal cut without bevel (see cut level 3, red color).

 A 45 degree angle bevel is associated with more exposed
dentinal tubules on the cut root surface, which can be
associated with an increased risk of bacterial microleakage
postoperatively

Microsurgery suggests a 0◦ bevel, perpendicular to the long axis of the
tooth
 A 0 degree bevel fulfills the following requirements:
 Preservation of root length.
 Less chance of missing lingual anatomy and multiple accessory canals.
 Complete root end resection.
 Less exposed dentinal tubules.
 Dentinal tubules are more perpendicularly oriented to the long axis of
the tooth and therefore a short bevel will expose fewer tubules.
 Easier to perform a root end preparation coaxially with the root. The
root end preparation should be kept within the long axis of the root to
avoid risk of a perforation. The longer the bevel, the more difficult it is
to orient and perform a preparation coaxially with the tooth

Methylene blue staining
 The resected root end is rinsed and dried with an irrigator (Stropko
Irrigator, Vista Dental, Racine, WI, USA).
 The dried surface is then stained with 1% methylene blue (MBS) ,
which is allowed to remain undisturbed on the resected surface for
10–15 s before once again gently flushing with a sterile solution and
drying with an irrigator .
 As the MBS only discolors organic material, it readily defines the
anatomy within, or around, the resected root end with a deep blue
color.
 If there are any fractures, tissue remnants in the isthmus, or
accessory canals present, the staining process will greatly enhance
the operator’s ability to see them.
 When used properly, the MBS will delineate the periodontal
ligament and the operator can be sure the apex has been completely
resected

Methylene blue staining...
 To obtain the maximum benefits of MBS, and to
inspect the bevelled surface thoroughly:
 The surface must be clean and dry before applying
the MBS
 The MBS must be applied for 10–15 s to saturate the
surface and periodontal ligament
 The surface must then be rinsed and dried
thoroughly
 The REB should be examined using varying powers
of the SOM to see whether the RER is complete and
to insure that no abnormalities are present.

Methylene blue staining...
 If after MBS there is an accessory canal present, the easiest
way to manage this anatomical entity is to bevel past it and
re-stain the surface to be sure that the defect is completely
eliminated.
 Alternately, the accessory canal can be simply ‘troughed
out,’ leaving the bevel as it is.
 If a white background such as Telfa pads, CollaCote, or
calcium sulfate has been used to aid in hemostasis, or
vision enhancement, it should be replaced after staining so
that more light is reflected and vision renewed.

To summarize root end resection..
 A root resection of 3 mm from the apex is indicated
and should be made perpendicular to the long axis of
the root.
 Root resection should be done at a midrange
magnification (e.g., ×10).
 The bevel angle of root resection should be shallow,
from 0 to 10 degrees.
 Apical curettage addresses only the symptoms of
pathology, not the cause

Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review.
Journal of Endodontics. 2006 Jul 1;32(7):601-23.

 Determining how much root tip to resect depends on the
incidence of the lateral canal and apical ramifications at
the root end. This question was examined by using the
Hess model of root anatomy.
 Using a computer system, the authors resected the roots of
the Hess models 1, 2, 3 and 4 mm from the apex, counting
the incidence of lateral canals and apical ramifications at
each level.
 Results of this study revealed that resecting 1 mm off the
apex reduces 52% of apical ramifications and 40% of
lateral canals
 2 mm off the apex reduces 78% of apical ramifications and
86% of lateral canals.
 Three millimeters off the apex reduces 93% of apical
ramifications and 98% of lateral canals.
Kim S, Pecora G, Rubinstein R. Color Atlas of Microsurgery in Endodontics. Philadelphia: W.
B. Saunders; 2001

ISTHMUS
 An isthmus is defined as a narrow strip of land
connecting two larger land masses or a narrow anatomic
part or passage connecting two larger structures or
cavities.
 An isthmus is defined as a narrow, ribbonshaped
communication between two root canals that contains
pulp, or pulpally derived tissue.
 Also called a corridor, a lateral connection, and an
anastomosis.
 It can be either complete or partial/incomplete
 In many cases, a tooth with a fused root has a web-like
connection between two canals and this connection is
called an isthmus .
 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.
Endodontics. 2006 Jul 1;32(7):601-23.

CLASSIFICATION
 Hsu and Kim (1997) described five different types of isthmus
Type I is defined as either two or three canals
with no noticeable communication.
Type II is defined as two canals that had a
definite connection between the two main canals
Type III differs from type II in that there are
three canals instead of two.
Incomplete C-shapes with three canals is also
included in a type IV isthmus.
Type V is identified as a true connection or
corridor throughout the section
Ingle JI, Baumgartner JC. Ingle's endodontics. PMPH-USA; 2008.

 A study was conducted to analyse the occurrence of canal isthmuses in
molars following root-end resection.
 The material consisted of 56 mandibular and 32 maxillary first molars
subjected to periradicular surgery. Based on radiographic, clinical, as
well as intraoperative status, only roots with associated pathological
lesions were treated. In total, 124 roots were resected (80 mandibular
and 44 maxillary molar roots). The cut root faces were inspected with a
rigid endoscope following apical root-end resection. The number of
canals as well as the presence and type of canal isthmuses were
recorded.
 In maxillary first molars: 76% of resected mesio-buccal roots had
two canals and an isthmus,10% had two canals but no isthmus, and
14% had a single canal. All disto-buccal and palatal roots had one
canal.
 In mandibular first molars: 83% of mesial roots had two canals
with an isthmus. In 11%, two canals but no isthmus were present, and
6% demonstrated a single canal. Sixty-four per cent of distal roots had
a single canal and 36% had two canals with an isthmus.
von Arx T. Frequency and type of canal isthmuses in first molars detected by endoscopic inspection
during periradicular surgery. Int Endod J 2005;38:160.

TYPE I TYPE II

TYPE III TYPE IV

TYPE V

 Weller et al. were one of the first to point out the significance of the
isthmus in surgical endodontics.
 In mesiobuccal roots of the maxillary first molar with two root
canal systems, they reported the highest incidence of an isthmus
occurred in the apical 3 to 5 mm and that an isthmus was present
100% of the time at the 4 mm level.
 In a micro-computed tomographic study, an isthmus was found to
be present in 85% of the time in the mesial root of the mandibular
first molars evaluated.
 This incidence of isthmuses in the mesial root of mandibular first
molars is very close to the 83% reported in a clinical surgical study.
Mannocci F, Peru M, Sherriff M, et al. The isthmuses of the mesial root of mandibular molars: A micro-computed tomographic
study. Int Endod J 2005;38:558

ROOT-END SURFACE
PREPARATION
Root-end surface
topography
Root-end conditioning
Citric acid, tetracycline,
and ethylenediamine
tetraacetic acid (EDTA)

Stropko JJ, Doyon GE, Gutmann JL. Root‐end management: resection, cavity preparation,
and material placement. Endodontic Topics. 2005 Jul 1;11(1):131-51.

ROOT END PREPARATION
LONG-AXIS
PREPARATION
PERPENDICULAR TO
THE LONG-AXIS
PREPARATION
VERTICAL SLOT
PREPARATION
TRANSVERSE SLOT
PREPARATION
REVERSE CANAL
INSTRUMENTATION

LONG-AXIS PREPARATION
 These handpiece are angled 2.5 mm
high and 4mm wide distal end to
facilitate proper root end preparation
in the long axis of the canal.
 Burs available are a #1 round bur and
a #34 inverted cone,but sometimes
these burs are too large for the root.
 The recommended depth of
preparation has ranged from 1 to 5
mm, with 2 to 3 m being the most
commonly advocated

PERPENDICULAR TO THE LONG-AXIS
PREPARATION
 This technique is probably the
most common approach to
root end preparation.
 Its use is dictated by access, root
anatomy, armamentarium and
surgeon experience.
 Any style of hand piece can be
used with # ½ or #1 round bur to
create the initial preparation.
 This is followed by #33 ½ or #34
inverted cone for retention.
Preparation commences with the
placement of the bur
perpendicular to the root face.

PERPENDICULAR TO THE LONG-AXIS
PREPARATION...
 The bur penetrates to an approximate depth of 2 to 3 mm,
encompassing the entire outline of the visible canal system.
 Undercuts are made by lightly rocking the bur in a mesial and
distal direction.
 Buccal retention is achieved with #12 or #14 wheel bur, which
can be counter sunk both buccally and proximally along the
labial wall of the preparation

VERTICAL SLOT PREPARATION
 Von Hippel used this approach to aid in
reverse canal instrumentation when a
post core was present.
 In 1950, Ruud modified this technique
with the addition of distinct undercut
areas for filling retention.
 Technically, as practiced today, a 5 to 7
mm vertical cut is made with a parallel
crosscut, fissure bur (#556/557) from
the labial or buccal, to the depth of the
lingual wall of the canal.

VERTICAL SLOT PREPARATION...
 A round bur, slightly larger than the fissure bur, is inserted into
the area of the canal and dropped coronally to the base of the
vertical cut.
 The round bur is then pulled out to the labial or buccal creating
an additional retentive channel.
 This procedure establishes a dovetailed, retentive cavity with
access for placement of a reverse fill from either the buccal root
surface or the resected root surface.

VERTICAL SLOT
PREPARATION...
 Various modifications have been made
to the “slitsmetoden”.
 They include the use of a small inverted
cone (#34/35) to create lingual
retentive undercut, tapered fissure burs
to prepare the vertical cut (#700/701),
decreasing the depth of the vertical cut
from 5 – 7 to 3 -5 mm, and the
elimination of either the labial or the
lingual undercut.

 5 distinct advantages :
1. Good surgical access to roots placed deep in bone
2. Distinct areas of cavity retention created
3. All possible dentinal tubules which may communicate from the
root face to main canal are sealed
4. Minimal amounts of root structure removed during resection
and bevels do not have to be highly accentuated in a coronal
direction
5. Use of slot preparation in roots with canals joined by
anastomoses encompasses entire root canal system with a
preparation designed to provide sufficient space for filling
materials

 Disadvantages:
1. Difficulty in visualizing the lingual portion of the
root
2. Increased size of apical preparation
3. Greater surface contact of filling materials with the
reparative tissues

TRANSVERSE SLOT PREPARATION
 A sufficient amount of facial bone
is removed to create direct access
to the root.
 A preparation is made prior to root
end resection, from the proximal or
directly from the buccal into the
root to the depth of the lingual wall
of the canal, depending on the
tooth and its position in the arch.
 Retention is established internally,
similarly to the vertical slot
preparation, only rotated 90
degree.

 Harnisch, claims this approach should be avoided because
it requires the removal of excessive amounts of facial bone.
 Holland and coworkers, used this technique to evaluate
marginal leakage around commonly advocated apical filling
materials. They found that root-end preparation techniques
down the long axis of the canal provided a better marginal
seal than the transverse slot preparation

REVERSE CANAL INSTRUMENTATION
 This approach to root-end preparation has been advocated
when canal cleaning and shaping has not occurred through
the crown or the canal space cannot be reached through the
crown and periradicular surgery is necessary
 Indications that have been cited include poorly cleaned,
shaped, and obturated canals with a post-core present,
coronal canal calcification with apical patency, separated
instruments in the mid-root, abutment teeth with artifical
crowns and short length which require surgery, and a
perforation or ledge in the mid-root portion which prevents
access to the apical half of the canal.

 This technique has been suggested for use with or without
root-end resection.
 K-files or Hedstrom files are bent at a 900 angle and
held in a hemostat or special holder .
 The patent portion of the canal is cleaned and shaped for
obturation with gutta-percha point , injected cement,
reverse silver point fills .
 The use of this technique is not recommended to supplant
good non-surgical cleaning, shaping, and canal obturation.
REVERSE CANAL INSTRUMENTATION

Why microsurgery?
 In the past, root end Class I cavity preparations or slottype
cavity preparations were prepared by a miniature contra-
angle handpiece with small burs or a straight slow speed
handpiece.
 Using this type of method, coaxial root end preparation
along the root canal was not possible. Furthermore, it
caused frequent perforation in the lingual side of the root.

 ULTRASONIC UNITS
 Create vibrations in the range of 30 to 40 kHz by exciting
quartz or ceramic piezoelectric crystals in the handpiece.
 The energy created is carried to the ultrasonic tip, producing
forward and backward vibrations in a single plane.
 Continuous irrigation along the cutting tip cools the surface and
maximizes debridement and cleaning.
 The three most widely used ultrasonic units are the EMS, the
Spartan (Spartan/Obtura), and the P-5 (Acteon).
 It is strongly advised to have a unit that has both Piezotome for
Groove preparation and ultrasonic root end preparation.
Currently, Acteon P-5 has both capabilities.

 This study compared the appearance of root-end cavity preparations
and the time required to prepare them using prototype ultrasonic
diamond-coated (DC) and stainless-steel (SS) retrotips.
 In 12 maxillary and 12 mandibular molar teeth 48 root-end cavities
were prepared ultrasonically in the palatal, mesio-buccal, distal and
mesial root-ends using DC and SS retrotips, alternately.
 Replicas of the resected root tips and the root-end cavities were
examined under a scanning electron microscope (SEM), recording (i)
incidence and extent of dentine cracks (ii) minimum remaining
thickness of the dentine walls and (iii) surface quality of the resected
root-ends.
 The time taken to complete the preparation was also recorded.
Means of these parameters were compared for both types of retrotips
using nonparametric tests.
Peters CI, Peters OA, Barbakow F. An in vitro study comparing root‐end cavities prepared by
diamond‐coated and stainless steel ultrasonic retrotips. International endodontic journal. 2001 Mar
1;34(2):142-8.

 No resected root-ends had cracks before preparation. However, after
preparation one root-end cavity shaped by an SS retrotip had a
microcrack visible at 23x magnification. Four and seven other root-
ends had crazed surfaces in the DC and SS groups, respectively (P >
0.05).
 Remaining minimum dentine thickness was 0.56 +/- 0.28 mm and
0.71 +/- 0.24 for the DC and SS groups, respectively, and this
difference was significant (P < 0.05).
 A root-end cavity in one specimen in the DC group was perforated.
Preparation times ranged from 25 sec to 361 sec and were
significantly lower for DC tips (P < 0.01) than the SS tips. The time
required to prepare root-end cavities also differed between roots;
root-end preparation in mandibular molars was more time
consuming.
1;34(2):142-8.

 They concluded that a better quality surface was produced by the
prototype diamond-coated retrotips, in less time than the
SS retrotips, which in turn caused fewer cracks than previously
reported.
 DC retrotips removed more dentine than SS retrotips and should
therefore be used with care to avoid overpreparation or
perforation.
1;34(2):142-8.

 The requirements for an REP include:
 The apical 3 mm of the canal system is
thoroughly cleaned and shaped;
 The preparation is parallel to, and
centered within, the anatomic outline of
the pulpal space;
 There is adequate retention form for the
root end filling material used
 All isthmus tissue is removed; and
 The remaining dentinal walls are not
weakened.

 The conventional root-end cavity preparation technique using
rotary burs in a micro-handpiece poses several problems for the
surgeon:
1. Access to the root-end is difficult, especially with limited
working space
2. There is a high risk of a perforation of the lingual root-end or
cavity preparation, when it does not follow the original canal
path
3. There is insufficient depth and retention of the root-end filling
material
4. The root-end resection procedure exposes dentinal tubules
5. Necrotic isthmus tissue cannot be removed
Endodontics. 2006 Jul 1;32(7):601-23.

ULTRASONIC TIPS
 The first ultrasonic tips for endodontic surgery were stainless steel Carr
Tips (CT 1–5) in 1990.
 In 1999 Spartan/Obtura introduced KiS (Kim Surgical) tips .
 The KiS ultrasonic tips have a better cutting ability and a more efficient
irrigation port.
 They are coated with zirconium nitride and have an irrigation port
near the tip rather than along the shaft.
 The enlarged view of a KiS tip shows the 3-mm cutting tip.
 These advanced tips cut faster and smoother and cause fewer
microfractures because of the improved positioning of the irrigation
port.

 KiS 1 tip : has an 80 degree angle and is 0.24 mm in diameter :
designed for the mandibular anterior teeth and premolars.
 KiS 2 tip: has a wider diameter tip and is designed for wider
teeth (e.g., maxillary anteriors).
 KiS 3 tip : is designed for posterior teeth. It has a double bend
and a 75 degree angled tip for use in the maxillary left side or
the mandibular right side.
 KiS 4 tip: is similar to the KiS 3 except that the tip angle is 110
degrees, to reach the lingual apex of molar roots.
 KiS 5 tip: is the counterpart of the KiS 3 for the maxillary right
side and the mandibular left side.
 KiS 6 tip: is the counterpart of the KiS 4 tip

 Recently Jet Tips were introduced
 A special feature of this tip is microprojection of the cutting surface
allowing quick and complete removal of gutta percha from the canal.
 They have bendable ultrasonic tips (B&L Biotech), which the operator
can bend in any direction for better access.
 JETips are available with 2 mm, 3 mm, 4 mm, 5 mm, and 6 mm tips
that allow for bending with a tip bending jig that will provide a
customized tip angle to meet all microsurgical needs

 In terms of pressure during ultrasonic preparation, the key
is an extremely light touch in a repeated fashion.
 A lighter touch increases the cutting efficiency, whereas a
continuous pressure, similar to the way a handpiece is used,
decreases the cutting efficiency.
 That is because ultrasonics work through vibration, not
through pressure.

 If resistance is met during ultrasonication, then a typical
high pitch sound is produced.
 This means that the tip is cutting against dentin.
 At that point the operator should stop the preparation, go
to a low-range magnification of the microscope, realign the
tip with the long axis of the root and start again
 If this step is not taken, then transportation or a
perforation of the root might occur either on the lingual or
distal dentinal wall
 Thus, it is important that the tip alignment has to be
parallel to the long axis of the canal

 When root end preparation is done in the correct direction,
no sound is heard and gutta percha is “walking” out of the
preparation
 A larger tip in diameter should be used in cases where
instrumentation and obturation was done to a large size, as
in teeth with wide or oval-shaped canals, and a smaller
diameter tip should be used for thinner canals.

 Once the apical preparation has been completed,
gutta percha should be compacted with a
microcondenser and the preparation should be dried
and inspected with a micromirror.

ROOT-END FILLING
 An ultrasonically prepared 3 mm class I cavity preparation
must be filled with a material that guarantees a hermetic seal.
 In the past several materials have been used for root end filling:
 Amalgam, gold foil, zinc oxide eugenol cements, Diaket (ESPE
GmbH, Seefeld, Germany), glass ionomer cements (GICs),
composite resins, intermediate restorative material (IRM, Caulk/
Dentsply, Milford, DE, USA) and SuperEBA (Keystone
Industries, Gibbstown, NJ). Mineral trioxide aggregate (ProRoot
MTA, Dentsply Interantional, Dentsply-Tulsa Dental, Tulsa, OK,
USA), and EndoSequence Root Repair Material (EndoSequence
root repair material (RRM) Brasseler, USA

 Some of the available carriers used to place MTA into
the REP include the Retrofill Amalgam Carrier
(Miltex, York, PA, USA), the Messing Root Canal
Gun (Miltex), Dovgan MTA Carriers (Quality
Aspirators, Duncanville, TX, USA) (Fig. 30A), the
MAP System (PD, Vevey, Switzerland) (Fig. 30B),
and the Lee MTA Pellet Forming Block (G. Hartzell &
Son, Concord, CA, USA)

MTA
 Torabinejad and others developed MTA (ProRoot) at Loma
Linda University.
 The main molecules present in MTA are calcium and
phosphorous ions, derived primarily from tricalcium silicate,
tricalcium aluminate, tricalcium oxide, and silicate oxide.
 Its pH, when set, is 12.5 and its setting time is 2 hours and 45
minutes.
 The compressive strength of MTA is reported to be 40 MPa
immediately after setting and increases to 70 MPa after 21 days.
 The results of solubility testing of MTA (ADA specification #30)
indicated an insignificant weight loss following testing

The Lee mineral trioxide aggregate (MTA) pellet forming block greatly simplifies the process
of delivering MTA to the root-end preparation (REP). (A) The MTA mixed to a ‘putty-like’
consistency on a spatula is (B) placed onto the appropriate size groove in the Lee MTA block,
(C) pressed into the groove with a finger, (D) the surface around the groove is wiped clean
with a finger, (E) the desired length of the MTA is selected, (F) to be removed by instrument,
and (G) carried to the REP in an efficient manner.

 Biocompatibility of gMTA and wMTA was compared by
evaluating cell attachment and osteogenic behavior.
 Perez et al.demonstrated that there was no initial difference
in the cell attachment, but the cells on wMTA did not
survive as long as on the gMTA.
 On the contrary, Camilleri et al. directly compared the
biocompatibility using a cell culture method and concluded
that the samples of two commercial forms of MTA showed
good biocompatibility
Pérez AL, Spears R, Gutmann JL, Opperman LA. Osteoblasts and MG-63 osteosarcoma cells
behave differently when in contact with ProRoot MTA and White MTA. Int Endod J 2003;36:564
–70
Camilleri J, Montesin FE, Papaioannou S, McDonald F, Pitt Ford TR. Biocompatibility of two
commercial forms of mineral trioxide aggregate. Int Endod J 2004;37:699 –704.

Microplugger Instruments
 After placement of MTA or Bioceramic putty into the root
end preparation using the Lee carver, the filling materials
need to be gently condensed to fill the whole root end
preparation length of 3 mm or a longer length.
 This procedure is done using micropluggers, one a thin 2-
mm diameter and another a thick 4-mm diameter,
depending on the size of root end preparation

FLAP REPOSITION AND SUTURING
 The continuous sling suture and the single knot interrupted
suture are the most commonly used types of suture in
endodontic microsurgery.
 The sling suture is generally used in molar surgery.
 The single knot interrupted suture is generally used when a
submarginal flap has been incised or when we would like to
secure an extended intrasulcular incision.
 An intrasulcular incision is generally sutured using a 5.0
monofilament or chromic gut suture.
 A submarginal incision is generally sutured using a 6.0 or
7.0 monofilament suture.
 It is advisable to remove the sutures after 48–72 hour

Endodontics. 2006 Jul 1;32(7):601-23.

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