Microsurgery in Endodontics

Syngcuk Kim, DDS, PhD, MD (Hon), is Louis I. Grossman Professor and Chairman Emeritus in the Department of Endodontics and Associate Dean for Global Affairs at the University of Pennsylvania School of Dental Medicine in Philadelphia, Pennsylvania, USA, and maintains a private practice in New York, New York, USA. Samuel Kratchman, DMD, is Clinical Associate Professor and Assistant Director of Graduate Endodontics and Director of Microsurgery in the Department of Endodontics at the University of Pennsylvania School of Dental Medicine in Philadelphia, Pennsylvania, USA, and maintains three private practices limited to endodontics in Exton, West Chester, and Paoli, Pennsylvania, USA. Associate Editors Bekir Karabucak, DMD, MS, is Chair and Associate Professor of Endodontics, Director of the Postdoctoral Endodontics Program, and Director of the Division of Advanced Dental Education at the University of Pennsylvania School of Dental Medicine in Philadelphia, Pennsylvania, USA, and maintains a private practice in Philadelphia, Pennsylvania, USA. Meetu Kohli, DMD, is Clinical Associate Professor of Endodontics and Director of the Continuing Education and International Program in the Department of Endodontics at the University of Pennsylvania School of Dental Medicine in Philadelphia, Pennsylvania, USA, and maintains two private practices limited to endodontics in Oaks and Gilbertsville, Pennsylvania, USA. Frank Setzer, DMD, PhD, MS, is an Assistant Professor, Clinical Director, and Pre-Doctoral Program Director in the Department of Endodontics at the University of Pennsylvania School of Dental Medicine in Philadelphia, Pennsylvania, USA, and maintains a private practice in Philadelphia, Pennsylvania, USA.

Contributors xiii

Preface xv

Acknowledgements xvii

1 The Dental Operating Microscope 1
Frank Setzer

1.1 Benefits of the Operating Microscope 1

1.2 Key Features of Operating Microscopes 1

1.3 Customizing a Microscope 3

1.3.1 Light Source 3

1.3.2 Documentation 5

1.3.3 Individual Microscope Adjustment (Parfocaling) 5

Suggested Readings 7

2 Microsurgical Instruments 9
SeungHo Baek and Syngcuk Kim

2.1 Examination Instruments 9

2.2 Incision and Elevation Instrument 9

2.3 Tissue Retraction Instruments 11

2.4 Osteotomy Instruments 14

2.5 Curettage Instruments 14

2.6 Inspection Instruments 15

2.7 Ultrasonic Units and Tips for Root End Preparation 17

2.8 Microplugger Instruments 20

2.9 Suturing Instruments 20

2.10 Miscellaneous Instruments 22

3 Medication-Related Osteonecrosis of the Jaw and Endodontic Microsurgery 25
Chafic Safi and Bekir Karabucak

Suggested Readings 29

4 Indications and Contraindications 31
Bekir Karabucak and Garrett Guess

4.1 Introduction 31

4.2 Surgical Success Dependent on Ability to Perform Ideal Protocols 31

4.3 Etiology Assessment through Examination and Treatment 31

4.4 Periodontal Considerations and Surgery 33

4.5 Influential Patient Factors 33

4.6 Condition of Previous Endodontic Treatment 37

Suggested Readings 38

5 Anesthesia and Hemostasis 39
Siva Rethnam-Haug, Aleksander Iofin, and Syngcuk Kim

5.1 Armamentarium 39

5.1.1 Epinephrine 39

5.2 Presurgical Phase 40

5.2.1 Administration of Local Anesthetic 40

5.2.2 Injection Techniques 40

5.2.3 Topical Anesthesia 41

5.2.4 Additional Techniques 41

5.2.5 Maxillary Anesthesia 41

5.2.6 Mandibular Anesthesia 43

5.2.7 Bilateral Mandibular Surgery 43

5.3 Surgical Phase 44

5.3.1 Topical Hemostatic Agents 44

5.3.1.1 Epinephrine Pellets 45

5.3.1.2 Ferric Sulfate 45

5.4 Summary of Hemostatic Techniques in Endodontic Microsurgery 46

5.5 Postsurgical Phase 46

Suggested Readings 48

6 Flap Design in Endodontic Microsurgery 49
Francesco Maggiore and Frank Setzer

6.1 Armamentarium 49

6.1.1 Flap Outline 49

6.1.2 Papilla Management 52

6.1.3 Incision 54

6.1.4 Flap Elevation 54

6.1.5 Flap Retraction 55

Suggested Readings 56

7 Osteotomy 57
Francesco Maggiore and Syngcuk Kim

7.1 Armamentarium 57

7.2 Osteotomy 57

7.2.1 Distinction between Bone and Root Tip 57

7.2.2 Clinical Situations for Endodontic Microsurgery 58

7.3 Intact Cortical Plate without a Radiographic Periapical Lesion 59

7.4 Intact Cortical Plate with a Periapical Lesion 60

7.5 Fenestration through the Cortical Plate Leading to the Apex 60

7.5.1 Optimal Osteotomy Size 61

7.5.2 Key Hole Osteotomy Modification 61

7.5.3 BoneWindow Technique 61

8 Root End Resection 67
Spyros Floratos, Fouad Al-Malki, and Syngcuk Kim

8.1 Armamentarium 67

8.2 Root End Resection 67

8.3 Root End Resection: Steep Bevel versus Shallow Bevel 69

Suggested Readings 72

9 Inspection of the Resected Root Surface: Importance of Isthmus 73
Spyros Floratos, Jorge Vera, Fouad Al-Malki, and Syngcuk Kim

9.1 Armamentarium 73

9.1.1 Methylene Blue Staining (MBS) 73

9.1.2 Isthmus 77

9.1.3 Types of Isthmus 77

9.1.4 Incidence 77

9.1.5 Histological Findings of Isthmus 79

9.1.6 Clinical Significance and Management 81

Suggested Readings 82

10 Ultrasonic Root End Preparation 83
Spyros Floratos and Syngcuk Kim

10.1 Armamentarium 83

Suggested Readings 89

11 MTA and Bioceramic Root End Filling Materials 91
Sujung Shin, Ian Chen, Bekir Karabucak, SeungHo Baek, and Syngcuk Kim

11.1 Mineral Trioxide Aggregate (MTA) 92

11.1.1 Advantages of MTA 92

11.1.1.1 Sealing Ability 92

11.1.1.2 Biocompatibility and Bioactivity 92

11.1.2 Drawbacks of MTA 93

11.2 Bioceramics 93

11.3 MTA and Bioceramic Application During Apicoectomy 95

11.4 Other Types of Cements for Root End Filling 96

11.4.1 Intermediate Restorative Material (IRM) 97

11.4.2 Super Ethoxybenzoic Acid (SuperEBA) 97

11.4.3 Geristore and Retroplast 98

11.4.4 New Types of Cements for Root End Filling 98

Suggested Readings 98

12 Flap Reposition and Suturing 101
Francesco Maggiore and Meetu Kohli

12.1 Suture Removal 101

Suggested Readings 111

13 PeriapicalWound Healing 113
Ingrida Dapkute, Georges Bandelac, Chafic Safi, and Frank Setzer

13.1 Principles ofWound Healing 113

13.2 Healing after Apical Microsurgery 113

13.3 Incomplete Healing/Scar Formation 113

13.4 Evaluation of Healing after Apical Surgery 114

13.5 Healing Evaluation Using CBCT 115

Suggested Readings 118

14 Cone Beam Computed Tomography 119
Garrett Guess, Fouad Al-Malki,Meetu Kohli, Bekir Karabucak, and Samuel Kratchman

14.1 How CBCT Works 120

14.2 Indications and Clinical Applications 120

Suggested Readings 142

15 Mental Nerve Management 143
Paula Mendez-Montalvo, Fouad Al-Malki, and Syngcuk Kim

15.1 Armamentarium 143

15.1.1 Mental Foramen and Nerve 143

15.1.1.1 Location 143

15.1.1.2 Anterior Loop 143

15.1.1.3 Number of Mental Foramina 144

15.1.2 Mental Foramen Detection on Radiographs 144

15.1.2.1 Periapical Radiograph 144

15.1.2.2 Panoramic Films 145

15.1.2.3 Cone Beam Computed Tomography (CBCT) 145

15.1.3 Neurosensory Alteration 145

15.1.3.1 Surgical Technique to Avoid Iatrogenic Mental Nerve Trauma and Injury 146

15.1.4 Groove Technique Using Piezoelectric Surgery 146

Suggested Readings 150

16 Maxillary Posterior Surgery, the Sinus, andManaging Palatal Access 151
Garrett Guess and Samuel Kratchman

16.1 Maxillary Premolars 151

16.1.1 Access 151

16.1.2 Instrumentation 151

16.2 Sinus Exposure 151

16.3 Maxillary First Molars 153

16.3.1 Access 153

16.3.2 Palatal Approach 155

16.4 Second Molars 159

16.4.1 Periodontal Aspects 161

Suggested Readings 162

17 Surgical Root Perforation Repair 163
Raed Kasem, Samuel Kratchman, and Meetu Kohli

17.1 Possible Challenges to Non-surgical Perforation Repair 163

17.2 Factors that Enhance Positive Long-Term Prognosis for Perforation Repair 164

17.3 Surgical Perforation Repair Techniques 166

17.4 Surgical Treatment for External Root Resorption 168

Suggested Readings 177

18 Intentional Replantation 179
David Li and Samuel Kratchman

18.1 Armamentarium 179

18.1.1 Success Rate 179

18.1.2 Indications 179

18.1.3 Replantation or Apicoectomy 179

18.1.4 Extraction 182

18.1.5 Extraoral Phase 183

18.1.6 Storage Medium 183

18.1.7 Replantation 183

18.1.8 Splinting 185

18.1.9 Postop Instructions 186

18.1.10 Cone Beam CT Scan 186

18.1.11 Repairing Procedural Mishaps 186

Suggested Readings 191

19 Guided Tissue Regeneration in Endodontic Microsurgery 193
Garrett Guess and Samuel Kratchman

Suggested Readings 202

20 Implants versus Endodontic Microsurgery 205
Frank Setzer and Syngcuk Kim

20.1 Historical Perspective 205

20.2 Benefits of Implants 205

20.3 Long-Term Prognosis of Dental Implants 205

20.4 Implant Complications 206

20.5 Long-Term Prognosis of Endodontically Treated Teeth with Root End Surgery 207

20.6 Conclusion 209

Suggested Readings 210

21 Prognosis of Endodontic Microsurgery 213
Meetu Kohli and Euiseong Kim

21.1 Best Available Evidence 213

21.2 Parameters for Success: Clinical and Radiographic 2D 214

21.3 Parameters for Success: “Penn 3D Criteria” for Assessing Healing on CBCT 215

21.4 Reversal of Success 215

21.5 TraditionalMethods 217

21.6 Modern Technique versus the Complete Microsurgical Approach 218

21.7 Root End Filling Materials 218

21.8 Case Selection 219

21.9 Resurgery 219

21.10 Summary 219

Suggested Readings 219

22 Positioning 221
Samuel Kratchman and Syngcuk Kim

22.1 Armamentarium 221

Suggested Readings 226

Index 227