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Nessa Publishers| www.nessapublishers.com

Journal of Oral Care and Dentistry

Volume 1| Issue 2

Research Article Open Access

The State of the Art in Micro-Surgical Endodontics Arnaldo Castellucci 1 * 1 University of Naples-Federico II, Italy *Corresponding author: Dr. Arnaldo Castellucci, Email: [email protected]

Citation: Arnaldo Castellucci (2017) The State of the Art in Surgical Endodontics: Nessa J Oral Care and Dentistry

Copyright: © 2017 Arnaldo Castellucci, et al. This is an open-access article distributed under the terms of the Creative

Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided

the original author and source are credited.

Abstract

In the last 15-20 years several important developments have been introduced in surgical endodontics: the ultrasonic

root end preparation, the surgical operating microscope and a new biocompatible material.

The introduction of the ultrasonic root end preparation made possible to obtain what is defined as the ideal

retropreparation: a class 1 preparation at least 3 mm into the root dentin with walls parallel to an coincident with the

anatomic outline of the pulpal space. In order to do this, special ultrasonic tips were developed to enable the clinician

to reach every root in all clinical situations.

The introduction of the surgical operating microscope represents another important development in surgical

endodontics as it has several advantages in surgical endodontics:

a) better visualization of the surgical field

b) better evaluation of the surgical technique

c) better accuracy during the entire procedure

d) better predictability of long term results

As far as the new materials are concerned, recently the Mineral Trioxide Aggregate became available. This is a

revolutionary material, which is extremely biocompatible, is hydrophilic, and is capable of stimulating the healing

processes and osteogenesis.

Thanks to all these revolutionary progresses, the long-term success rate of surgical endodontics is higher and

endodontic therapy today is more predictable and even more fun!

Keywords: Easy. Surgery, Apicoectomy, Retrofill, Microscope.


Journal of Oral Care and Dentistry Volume 1| Issue 2

By Surgical Endodontics one refers to that branch of Dentistry that is concerned with the diagnosis and treatment of

lesions of endodontic origin that do not respond to conventional endodontic therapy or that cannot be treated by

conventional endodontic therapy.1 The scope of Surgical Endodontics is to achieve the three dimensional cleaning,

shaping and obturation of the apical portion of the root canal system which is not treatable via an access cavity, but only

accessible via a surgical flap.

In the last 20-25 years three important developments have been introduced in surgical endodontics: the ultrasonic root

end preparation, biocompatible materials and the surgical operating microscope. Today, the entire procedure is

performed through the operating microscope, from anesthesia and incision up to the suture and the removal of suture.

In a recent article Setzer et al.2 conducted a meta-analysis and a systematic review of the literature. The authors

compared the outcomes of contemporary root-end surgery techniques with micro-instruments but only loupes or no

visualization aids with the outcomes of endodontic microsurgery using the same instruments and materials but with high

power magnification as provided by the surgical operating microscope. The conclusion of the study was that the

probability for success was significantly greater if the surgical procedure was performed using the high power

magnification rendered by the dental operating microscope. This conclusion is in agreement with the most recent

literature, 3-9 and depending of different studies, the success rate has been described of 98 %!

For this reason, it is correct to speak in terms of “Micro” (because the use of the microscope is today mandatory to

perform the entire procedure) and then “Surgical Endodontics” because, as stated before, it is an Endodontic procedure

performed through a surgical flap, and not just a surgical procedure performed just to remove periapical inflammatory

tissue. Therefore, it is something that is pertinent to the Endodontist and must be carried out with the knowledge, the

skillfulness, and the hand of the Endodontist. He or she will take care of cleaning, shaping and three-dimensionally

obturating the root canal system with a surgical approach, just because (this is what happens most of the time) the root

canal system was not negotiable non surgically (Fig. 1).

Fig 1a: Pre-operative radiograph of the upper left first molar. The two canals of the mesio-buccal root were not

negotiable. This is an indication for the surgical approach



Fig 1b: Post-operative radiograph. MB1, MB2 and the isthmus have been obturated with white MTA

Fig 1c: Recall radiograph after 2 years

Diagnosis and Treatment Plan

Once a diagnosis of endodontic failure has been made, it is necessary to understand what the cause of the failure was so

that successively the possibility of correcting the failure by orthograde retreatment can be evaluated. Only in the case

where this possibility does not exist or better still after failure of the non-surgical therapy carried out to resolve the

problem, only then is one authorized to intervene surgically. Apical Surgery in other words is not a substitute for

incomplete debridement and poor endodontics and the real indication for the surgical endodontic treatment is just

mechanical.



In agreement with what Nygaard-Ostby and Schilder 10 confirmed, Surgical Endodontics must be reserved for those cases

in which the preparation and obturation of the root canal appear impossible right from the beginning or when the non-

surgical retreatment attempts have failed. Nevertheless, even in such cases, the authors recommend filling as much of the

root canal by conventional method as possible.

Ultimately even after the indication for surgery has been established, in agreement with Weine and Gerstein, 11 it is

recommended to remove as much as possible of the inadequate preceeding canal obturation material and replace it with

well compacted gutta-percha: in this way lateral canals, forgotten additional canals can be filled, often removing the need

for surgery. Nevertheless, in those cases which still have the indication for surgery it is currently possible to have a

notably increased percentage of success with the treatment of surgical cases compared with what could be attained up

until a few years ago, and this is thanks to recent technological progress and new materials today available for surgical

endodontics. As already stated, in the last 25 years three important developments have been introduced in surgical

endodontics: the surgical operating microscope,12,13 the ultrasonic root end preparation12,14 and the use of new

biocompatible materials for the retrofill of the root canal system.15

The Surgical Operating Microscope

The introduction of the surgical operating microscope represents a very important development in surgical endodontics.12

For many years periapical surgery has been performed without any magnification, using the dental light as the only light

source to illuminate the surgical field. No surprise therefore if until recently the success rate after surgery was much

lower compared to nonsurgical endodontics.16 To increase visibility, surgical telescopes or loops and surgical headlamps

became available. Loops are available in a variety of configurations and magnifications, starting from 2x up to 6x, with

Galileian optics or prismatic optics. When a fiberoptic headlamp is added to the loops, a coaxial light is projected into the

surgical field, so that both magnification and illumination are enhanced.

On the other hand, clinicians who have benefited from the use of loops and headlamps soon understand the limitations of

this system. Magnification of 6x sooner or later is not enough anymore and the headlamp is not capable to send the light

deep into the canal in surgical and nonsurgical endodontics. Furthermore, at that magnification the operative field is quite

small and the depth of field is also reduced, with consequent strain for the head and neck.

The surgical operating microscope has a range of magnifications from 2.5x to 25x and the illumination is always

perfectly coaxial with the line of sight.

The coaxial illumination has two advantages: a) the clinician can look into the surgical field without any shadows (which

means for example that it is possible to examine the cleanliness of the retro-preparation during surgical endodontics); b)

since the coaxial illumination is made possible because the operating microscope uses Galileian optics, and since

Galileian optics focus at infinity and send parallel beams of light to each eye, the operator’s eyes are also focusing at

infinity and every procedure can be performed without any eye fatigue.



As far as the magnification is concerned, there is no need to go beyond 20-25x. Lower and medium magnifications are

used for operating; higher magnifications are used only for observing fine details. Working at high magnifications means

to have a very limited depth of field and limited illumination, and therefore is not practical.17

In conclusion, the use of the surgical operating microscope has several advantages in surgical endodontics:

a) better visualization of the surgical field;

b) better evaluation of the surgical technique;

c) better accuracy during the entire procedure;

d) better predictability of long term results.

For these reasons, the author is firmly convinced that surgical endodontics should not be performed without the use of

the microscope, from the injection of anesthesia to the removal of sutures.

The ultrasonic root end preparation

At the end of the ’80 Gary Carr made a big revolution in the field of the Periapical Surgery: he invented the ultrasonic

preparation of the root end and since then the use of low speed hand pieces and burs are no longer accepted as the

standard of care for apical surgery. Too many are the advantages of the Ultrasonic Root End Preparation compared to the

use of rotary hand pieces and burs:

1) it is now possible to clean the apical root canal at 360°, including the buccal aspect of the preparation

2) the preparation is made along the main axis of the root canal

3) the retroprep is smaller and consequently is easier to seal

4) the bony crypt is smaller and less dentin is removed using a short bevel

5) it is much easier to follow the root canal anatomy and to prepare isthmuses

6) the access is comfortable even in canals difficult to be reached, like the palatal canal of a first premolar, the MB2

of upper molars and the ML of lower molars

7) there is no need to make undercuts to give retention to the cavity and this means less risk to make perforations on

the palatal aspect of the retroprep

8) it is much easier to retreat a surgical failure and to remove the old amalgam retrofill, which most of the times can

be removed in one single piece, while using a bur a lot of amalgam dust was made with consequent high risk of

tattoo in the soft tissue.14



The only “disadvantages” of the use of ultrasonic tips are:

1) the tips are fragile and for sure they don’t last so long like the burs

2) more instruments are needed, like tips, ultrasonic units, and many micro-instruments, like mirrors, pluggers,

carriers etc.

3) the cost is therefore higher

4) the technique is not familiar for the operator who is invited to test the instruments first on extracted teeth.

Many recent articles agree that the use of micro-surgical techniques is superior in achieving predictably high success

rates for root-end surgery (93.52 %) when compared with traditional techniques (59 %).1-9

Several piezo electric units are available in the market, like Spartan, Satelec P-5, Amadent, EMS, and they all are very

efficient. Also several different kind of ultrasonic tips are available and the operator can choose depending on the

requested efficiency: the tips in stainless steel with no coating are the less effective, the tips chemically coated

(zirconium or titanium nitride) (Fig. 2) are more efficient and the diamond coated are definitely the most efficient. All of

them have a water port for the irrigation, since they must never work dry. The amount of irrigating solution is also very

important: too much irrigation will decrease the visibility, too little will overheat the dentin and can cause the fracture of

the tips. They have to be used at the minimum power, very gently, without finding any resistance while preparing the

retro-cavity. During the preparation of the retro-cavity it is suggested to work with the microscope al lower

magnification, in order to take into consideration the long axis of the root and consequently to orient the retrotip parallel

to the root canal (Fig. 3).

Fig 2a: Ultrasonic retrotips by Dentsply Maillefer



Fig 2b: The bony crypt is quite small

Fig 3: The retro-cavity is now ready to be obturated

Recently Dr. Khayat designed new longer ultrasonic tips diamond coated of 3, 6, and 9 mm of length (Fig. 4). They are

particularly useful in case when the surgical procedure is performed in root canals partially empty and therefore the

retroprep has to be particularly long. Of course these cases must still have the real indication for the surgical endodontic

treatment and they cannot be treated non-surgically. The three tips of different length have to be used in sequence,

always starting with the small one of 3 mm and then if there is room enough for the others, proceed with the one of 6 and

then 9 mm of length (Fig. 5).



Fig 4: Ultrasonic retrotips designed by Dr. Bertrand Khayat

Fig 5a: Pre-operative radiograph of the upper central incisors. The root canals have been obturated with a surgical

approach during the previous surgical procedure



Fig 5b: The tip of 9 mm of length is entering in the root canal

Fig 5c: C. Recall radiograph after 2 years. The root canals have been prepared using in sequence the long tips and

obturated with thermoplastic gutta-percha and white MTA in the apical 3 mm.

Usually the surgery is made to retreat non-surgical failures and the root canal contains at least sealer or may be sealer and

gutta-percha. Therefore, the tip should not meet resistance while is cleaning the root canal from the previous material. If

the operator feels resistance, it means that the tip is working against the dentinal wall instead of just removing material

from the root canal. The only time when the operator will fill resistance is when the canal is completely calcified, it was

not negotiated before and it doesn’t contain any obturating material. In such a case, it is suggested to progress coronally

very slowly, checking every few seconds that the tip is going in the right direction. It is enough to stop, dry the field and

check with the micro-mirror that the calcified canal is always in the center of the retroprep.



In case of a root with two canals the operator should always remember that there is an isthmus, even though it is not

visible with the microscope. The isthmus used to contain vital pulp tissue, now it contains bacteria, therefore it must be

always included in the retro-preparation, must be cleaned and filled with the obturating material (Fig. 6). We know from

the recent literature that the mesio-buccal root of upper first molars has two canals 93 % of the time.18 This means that

the isthmus is present in the same percentage. The same is valid for upper second molars (59 %) and for the mesial roots

(80 %) and distal roots (20 %) of lower molars.

Fig 6a: The root resection is made almost at 90° to the long axis of the tooth and the isthmus is prepared and sealed.

Fig 6b: MB1, MB2 and the isthmus have been obturated with white MTA

When the retro preparation is completed, it is rinsed with the irrigation of the retrotip, dried with the Stropko irrigator

and inspected with the micro-mirror of adequate size, checking the cleanliness at several magnifications. Now the cavity

is ready to be filled.



Root End Filling Materials

The ideal retrofilling material should have the following characteristics:

1) easy to carry and to manipulate

2) relatively fast setting time

3) dimensionally stable and non resorbable

4) capable to guarantee a perfect seal of the cavity

5) biocompatible

6) non-toxic

7) insoluble in tissue fluids

8) bacteriostatic

9) sterile or easily sterilizable before use

10) radiopaque

11) easily removable if necessary

Many retrofilling materials have used through the years: amalgam, IRM, Super EBA, Optibond, Gerestore and more

recently Mineral Trioxide Aggregate (MTA).

Amalgam has been abandoned for many reasons, like leakage,19 corrosion,16 blood mercury level,20 and more so that it

can be concluded that there is no valid reason today to continue its use. Nevertheless, many Oral Surgeons and Maxillo

Facial Surgeons still use amalgam…21,22 The only advantage of amalgam was its radiopacity.

Super EBA has been used for many years, especially after the advent of the ultrasonic root end preparation.23 In the

Author’s experience Super EBA demonstrated to be an excellent material, showing a long term success rate of more than

91.5%.24 On the other hand, the material has few drawbacks. First of all it is technique sensitive, and it takes about 5

minutes of manipulation before being condensed into the cavity and several minutes for setting and finishing. The

material comes with two different kinds of powder, fast and slow setting time. It is not always easy to make the right

choice, so that sometimes the setting time is too fast and the material start the setting during the compaction, some other

times the setting takes forever… During the compaction the bleeding control must be perfect because the material cannot

be contaminated by blood. If this happens, the damaged material needs to be removed and the filling had to start all over

again. Another drawback that I found recently in my practice is the dimensional stability and the resorbability. In one

case I had to retreat my surgical failure and I found that the SuperEBA that I had positioned several years before was

completely washed out.



Composite materials like Optibond (SybronEndo) and Gerestore (Den-Mat, USA) can be used today thanks to the perfect

crypt control and the absolutely dry operative field.18 Like in restorative dentistry, the material doesn’t want to be

contaminated by any moisture and being positioned under the microscope, it is important to reduce the intensity of the

illumination as much as possible and use a filter to prevent a significant reduction of the setting time.18

Mineral Trioxide Aggregate (MTA; ProRoot MTA, Dentsply Tulsa Dental) became recently available and today there

are many articles in the literature showing that MTA can be considered the material of choice.14,19,25

MTA is an endodontic cement that is extremely biocompatible, capable of stimulating healing and osteogenesis, and is

hydrophilic. MTA is a powder that consists of fine trioxides (Tricalcium oxide, Silicate oxide, Bismute oxide) and other

hydrophilic particles (Tricalcium silicate, Tricalcium aluminate, responsible for the chemical and physical properties of

this aggregate), which set in the presence of moisture. Hydration of the powder results in formation of a colloidal gel

with a pH of 12.5, that solidifies to a hard solid structure in approximately three-four hours.15 This cement is different

from other materials currently in use because of its biocompatibility, antibacterial properties, marginal adaptation and

sealing properties, and its hydrophilic nature.15

In the Author’s experience, MTA has replaced all the previously mentioned materials for many reasons, first of all its

biocompatibility,26-28 its hydrophilic nature,15 then because it has superior sealing quality,29-34 is not affected by moisture

or blood contamination,31 it is relatively easy to manipulate and today an excellent carrier is available. MTA has several

advantages:

1) easy to mix and place into the cavity with a small carrier

2) since it sets in the presence of moisture, it is not moisture sensitive and is not affected by blood contamination

3) seals better than amalgam, Super EBA or IRM

4) has a better adaptation to the surrounding dentin

5) has excellent biocompatibility

6) activates cementogenesis.

The only disadvantage that existed years ago when the material was first introduced into the market was the difficulty to

handle just because there was not an adequate carrier. The first carrier that became available was the Dovgan Carrier

(Quality Aspirators, Duncanville, TX, USA), but even though the needles were bendable, its use was not comfortable

during surgery, especially in posterior teeth.



In the year 2000 another carrier was proposed by Edward Lee,35,36 the MTA Pellet Forming Block. After being properly

mixed to a putty-like consistency (not too dry and not too wet), the MTA is just pressed into the previously selected

groove of the Lee block, then a small spatula slides into the groove to take the selected length of material, this adheres to

the tip of the spatula and it is ready to be easily placed into the retroprep.

Recently, another carrier has been designed and manufactured by Produits Dentaires SA (Vevey, Switzerland) in

cooperation with Dr. Bernd Ilgenstein, called The MAP (Micro Apical Placement) System (Fig. 7) and this can be

considered an “universal” carrier, since it has special needles that can be used both in clinical and in surgical endodontics

and during surgery allows an easy positioning of MTA also in posterior teeth and in lateral canals.37

Fig 7a: The MAP System

Fig 7b: The needle acts as a carrier and also as a plugger, condensing the material inside the cavity

Once the retro-cavity has been prepared using the ultrasonic retro-tips and the bleeding of the bony crypt is under

control, the operator asks the dental assistant to mix the MTA to the correct consistency and then to handle the pre-fitted

applicator syringe. The consistency of MTA must be neither too wet nor too dry.



During the placement of MTA in the retro-cavity, the dental assistant is asked to touch the metal plugger with an

ultrasonic tip in order to release the entrapped air, to improve the adaptation to the cavity walls and to improve the

density of the obturating material. The material is always carried in excess, condensed with a big burnisher and then is

finished with a small spatula and a micro-brush to the level of the resected root end.

The MTA is hydrophilic and requires moisture to set. The necessary moisture will come from the blood which

immediately after surgery will fill the bony crypt.

Micro-Surgical Technique

Anesthesia

When treating teeth of the upper arch, only the topical anesthesia will be used.

When treating teeth of the lower arch, after obtaining the block of the inferior alveolar nerve then the topical anesthetic

will be injected in the entire area that will be involved in the surgical procedure (Fig. 8). The topical anesthesia is used

mainly and only to provide a good vasoconstriction in order to have a good control of the bleeding and then an excellent

visibility for the surgical team. For this reason, the anesthetic solution used is Lidocaine with epinephrine 1:50,000. This

is a “conditio sine qua non” to perform the surgical procedure, which in other words means: “No Epinephrine, no

Surgery”!

Fig 8: The anesthesia should involve the entire area of the surgical procedure, introducing the needle only few

millimeters in the mucosa, in order not to involve the beta receptors



The incision

The incision is made with the microsurgical blade CK2 (SybronEndo), which is much smaller then the BP #15 (Fig. 9).

The blade will allow to make more precise and accurate incisions, which later will allow a more accurate repositioning

and suturing of the flap and consequently a better and faster healing.

Fig 9: The Bard-Parker # 15 compared to the micro-blade of the CK2

The incision must always be made thinking of the later suture. Must be extended always one tooth mesial and one tooth

distal to the involved tooth.38 Must be large enough to allow adequate vision, atraumatic elevation and retraction, passive

repositioning and then an easy suture.

Various flap designs have been discussed in the literature:39-41

1) Semilunar flap

2) Marginal flap

3) Para-marginal flap

Basically, the incision should provide a good access and protect the epithelial attachment. The selection of the flap

design depends on several factors, like the integrity of the bone over the roots, the amount and nature of the attached

gengiva and the presence or absence of a fixed dental prosthesis.

The Semilunar flap

This flap has a concave design with the concavity towards the apex of the root. It is a full thickness flap and the incision

is made entirely in the alveolar mucosa. This is the incision usually preferred by the oral surgeons and the only

advantages of this flap are the respect of the epithelial attachment and the absence of a periodontal involvement: the

marginal tissue remains untouched and thus no recession will occur. On the other hand, there are many disadvantages,

like limited access to the surgical area, poor visibility, difficult control of the bleeding, the suture is not over healthy

bone, it is difficult to precisely reposition and suture the flap, the healing could be by secondary intention, and quite often

there are visible scars.

Because of the many drawbacks mentioned a semilunar flap design is no longer recommended.42



The Marginal flap

This flap design is most indicated when there is not enough attached gingiva and where esthetic is not a concern. For sure

this is the flap design of choice when a vertical root fracture is suspected, since it provides excellent visibility of the root

surface.

The disadvantage of this flap is represented by the epithelial involvement, which as consequences could have a

periodontal involvement. In case of the presence of fixed prosthesis involving subgingivally placed crown margins, a

postoperative sequel can result in recession, leading to esthetically compromising exposure of the crown margins.

The Para-marginal flap (Ochsenbein-Lubke)

The most popular submarginal flap is the flap design by Ochsenbein and Luebke.43 This flap is most indicated when there

is an adequate amount of attached gingiva and there is no periodontal involvement in the surgical area, being the probing

within normal limits. It is also better indicated in case of presence of dental restorations in the front area, in order not to

interfere with the cervical tissue and avoid later aesthetic problems. The flap is full-thickness and has one horizontal and

two vertical components (Fig. 10). The horizontal is made about 1 mm coronal the muco-alveolar junction, leaving at

least 2 mm of attached gingiva at the coronal margin of the flap. The incision has rounded scallops that follow the

architecture of the teeth and later will allow an easy and passive repositioning and suture. The incision must always

involve one tooth mesial and one tooth distal to the one being operated on. The two vertical components at each end of

the horizontal one are made as releasing incisions, in order to allow a passive and atraumatic reflection of the flap. The

releasing incisions must have a 90° rounded angle with the horizontal component, and must be parallel to the long axis of

the teeth, in order not to section the blood vessels who are also parallel to the long axis of the teeth. In case there is not

adequate amount of attached gingiva along the entire length of the horizontal component, the flap can be modified, being

a sulcular flap where there is no attached gingiva and para-marginal where there is attached gingiva. However, according

to Kramper et al,44 the para-marginal incision is the flap of choice in surgical endodontics, when not contraindicated by

the anatomical location of the lesion or by insufficient attached gingival tissue.

The ultrasonic root end preparation and the use of the retrofilling materials have already been described.



Fig 10: Schematic representation of the para-marginal flap

Suture

As already mentioned before, the suture can and should be done using the operating microscope. Suturing under the

microscope has the advantage of being more accurate in repositioning the flap, allowing a perfect healing by primary

intention, without any scar tissue. Ideally, the suture must keep the soft tissue in place during the time of healing and

should not encourage colonization of bacteria. If repositioning has been accurate as it should be, healing occurs by

primary intention in 24-48 hours and this is the reason why suture removal is indicated after 24-48 hours.45,46

Nonabsorbable silk sutures are easy to tie and handle but are no longer recommended as they accumulate plaque, allow

rapid bacterial colonization and are uncomfortable to remove because of ingrowth of tissue.45 However, some

multifilament suture materials seem to inhibit bacterial transmission.47 Nylon (Supramid, S. Jackson) (like any other

monofilament synthetic sutures) is colonized more slowly, allows less bacterial migration but is too rigid and often

patients complain because the suture is irritating the lip or the cheek. Tevdek (CK Dental Specialties) is a newly

introduced suture made of a polytetrafluoroethylene (PTFE) impregnated polyester material (PET). It is very resistant to

bacterial colonization and is nonirritating. The suggested size of the suture is 6-0 (Fig. 11).

Fig 11: Needle holder, suture and scissor for suturing



Suture removal

While the periodontists are dealing with deseased tissue, and quite often reposition the flap laterally, apically, coronally

so that healing comes by secondary intention, our flaps are passively elevated and passively repositioned exactly in their

original place, so that healing will progress by primary intention. This is true especially if the tissue has not been

traumatized during the surgical procedure and everything has been performed gently under the microscope.

According to Ruben et al.48 the epithelial creep occurs at a rate of about 1 mm per side per 24 hours. That means that if

the reapproximation performed under the microscope has been precise, the gap left by the incision is completely closed

after 24 hours and the suture has completed its task. In other words there is no need to keep the suture any longer. Now it

is just a foreign body that can only attract bacterial plaque, cause inflammation, delay healing and later will be

responsible of a scar. On the other hand, after the procedure has been performed under the microscope with a nice

scalloped incision, passive flap elevation and retraction, passive and precise repositioning, careful suture with a 6-0

filament, now the suture can be removed after 24 hours, with the result of very little or no scar at all (Fig. 12). Of course,

if the patient for some reason cannot come for the removal of the suture before of two or three days, there is no problem

but for sure the suture should not remain in place for one week or more…

Fig 12a: The suture Tevdek has been just positioned

Fig 12b: The suture was removed after 24 hours and the image taken after 2 years shows no scar



Conclusions

The introduction of microsurgery to surgical endodontics attempted to minimize trauma and enhance surgical results.

Micro-Surgical Endodontics is effective in saving natural teeth and the long term successfull rates have never been so

high like in these days.5 The probability of success for Micro-Surgical Endodontics proved significantly greater than the

probability of success for traditional root-end surgery. This demonstrates the evolution of periapical surgery and what

can be achieved with contemporary techniques including enhanced magnification and visualization. Regarding the

question whether microsurgical techniques are always needed in endodontic surgery or might not be necessary for certain

tooth types, recent meta-analysis studies concluded that the use of traditional root-end surgery techniques should not any

longer be considered state of the art.2,3

The influence of high-power magnification provided by the dental operating microscope and the superiority of

endodontic microsurgery over contemporary endodontic surgery with no or low magnification is today well known and

universally accepted.



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