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 EditorsBekir 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 xiiiPreface xvAcknowledgements xvii1 The Dental Operating Microscope 1Frank Setzer1.1 Benefits of the Operating Microscope 11.2 Key Features of Operating Microscopes 11.3 Customizing a Microscope 31.3.1 Light Source 31.3.2 Documentation 51.3.3 Individual Microscope Adjustment (Parfocaling) 5Suggested Readings 72 Microsurgical Instruments 9SeungHo Baek and Syngcuk Kim2.1 Examination Instruments 92.2 Incision and Elevation Instrument 92.3 Tissue Retraction Instruments 112.4 Osteotomy Instruments 142.5 Curettage Instruments 142.6 Inspection Instruments 152.7 Ultrasonic Units and Tips for Root End Preparation 172.8 Microplugger Instruments 202.9 Suturing Instruments 202.10 Miscellaneous Instruments 223 Medication-Related Osteonecrosis of the Jaw and Endodontic Microsurgery 25Chafic Safi and Bekir KarabucakSuggested Readings 294 Indications and Contraindications 31Bekir Karabucak and Garrett Guess4.1 Introduction 314.2 Surgical Success Dependent on Ability to Perform Ideal Protocols 314.3 Etiology Assessment through Examination and Treatment 314.4 Periodontal Considerations and Surgery 334.5 Influential Patient Factors 334.6 Condition of Previous Endodontic Treatment 37Suggested Readings 385 Anesthesia and Hemostasis 39Siva Rethnam-Haug, Aleksander Iofin, and Syngcuk Kim5.1 Armamentarium 395.1.1 Epinephrine 395.2 Presurgical Phase 405.2.1 Administration of Local Anesthetic 405.2.2 Injection Techniques 405.2.3 Topical Anesthesia 415.2.4 Additional Techniques 415.2.5 Maxillary Anesthesia 415.2.6 Mandibular Anesthesia 435.2.7 Bilateral Mandibular Surgery 435.3 Surgical Phase 445.3.1 Topical Hemostatic Agents 445.3.1.1 Epinephrine Pellets 455.3.1.2 Ferric Sulfate 455.4 Summary of Hemostatic Techniques in Endodontic Microsurgery 465.5 Postsurgical Phase 46Suggested Readings 486 Flap Design in Endodontic Microsurgery 49Francesco Maggiore and Frank Setzer6.1 Armamentarium 496.1.1 Flap Outline 496.1.2 Papilla Management 526.1.3 Incision 546.1.4 Flap Elevation 546.1.5 Flap Retraction 55Suggested Readings 567 Osteotomy 57Francesco Maggiore and Syngcuk Kim7.1 Armamentarium 577.2 Osteotomy 577.2.1 Distinction between Bone and Root Tip 577.2.2 Clinical Situations for Endodontic Microsurgery 587.3 Intact Cortical Plate without a Radiographic Periapical Lesion 597.4 Intact Cortical Plate with a Periapical Lesion 607.5 Fenestration through the Cortical Plate Leading to the Apex 607.5.1 Optimal Osteotomy Size 617.5.2 Key Hole Osteotomy Modification 617.5.3 BoneWindow Technique 618 Root End Resection 67Spyros Floratos, Fouad Al-Malki, and Syngcuk Kim8.1 Armamentarium 678.2 Root End Resection 678.3 Root End Resection: Steep Bevel versus Shallow Bevel 69Suggested Readings 729 Inspection of the Resected Root Surface: Importance of Isthmus 73Spyros Floratos, Jorge Vera, Fouad Al-Malki, and Syngcuk Kim9.1 Armamentarium 739.1.1 Methylene Blue Staining (MBS) 739.1.2 Isthmus 779.1.3 Types of Isthmus 779.1.4 Incidence 779.1.5 Histological Findings of Isthmus 799.1.6 Clinical Significance and Management 81Suggested Readings 8210 Ultrasonic Root End Preparation 83Spyros Floratos and Syngcuk Kim10.1 Armamentarium 83Suggested Readings 8911 MTA and Bioceramic Root End Filling Materials 91Sujung Shin, Ian Chen, Bekir Karabucak, SeungHo Baek, and Syngcuk Kim11.1 Mineral Trioxide Aggregate (MTA) 9211.1.1 Advantages of MTA 9211.1.1.1 Sealing Ability 9211.1.1.2 Biocompatibility and Bioactivity 9211.1.2 Drawbacks of MTA 9311.2 Bioceramics 9311.3 MTA and Bioceramic Application During Apicoectomy 9511.4 Other Types of Cements for Root End Filling 9611.4.1 Intermediate Restorative Material (IRM) 9711.4.2 Super Ethoxybenzoic Acid (SuperEBA) 9711.4.3 Geristore and Retroplast 9811.4.4 New Types of Cements for Root End Filling 98Suggested Readings 9812 Flap Reposition and Suturing 101Francesco Maggiore and Meetu Kohli12.1 Suture Removal 101Suggested Readings 11113 PeriapicalWound Healing 113Ingrida Dapkute, Georges Bandelac, Chafic Safi, and Frank Setzer13.1 Principles ofWound Healing 11313.2 Healing after Apical Microsurgery 11313.3 Incomplete Healing/Scar Formation 11313.4 Evaluation of Healing after Apical Surgery 11413.5 Healing Evaluation Using CBCT 115Suggested Readings 11814 Cone Beam Computed Tomography 119Garrett Guess, Fouad Al-Malki,Meetu Kohli, Bekir Karabucak, and Samuel Kratchman14.1 How CBCT Works 12014.2 Indications and Clinical Applications 120Suggested Readings 14215 Mental Nerve Management 143Paula Mendez-Montalvo, Fouad Al-Malki, and Syngcuk Kim15.1 Armamentarium 14315.1.1 Mental Foramen and Nerve 14315.1.1.1 Location 14315.1.1.2 Anterior Loop 14315.1.1.3 Number of Mental Foramina 14415.1.2 Mental Foramen Detection on Radiographs 14415.1.2.1 Periapical Radiograph 14415.1.2.2 Panoramic Films 14515.1.2.3 Cone Beam Computed Tomography (CBCT) 14515.1.3 Neurosensory Alteration 14515.1.3.1 Surgical Technique to Avoid Iatrogenic Mental Nerve Trauma and Injury 14615.1.4 Groove Technique Using Piezoelectric Surgery 146Suggested Readings 15016 Maxillary Posterior Surgery, the Sinus, andManaging Palatal Access 151Garrett Guess and Samuel Kratchman16.1 Maxillary Premolars 15116.1.1 Access 15116.1.2 Instrumentation 15116.2 Sinus Exposure 15116.3 Maxillary First Molars 15316.3.1 Access 15316.3.2 Palatal Approach 15516.4 Second Molars 15916.4.1 Periodontal Aspects 161Suggested Readings 16217 Surgical Root Perforation Repair 163Raed Kasem, Samuel Kratchman, and Meetu Kohli17.1 Possible Challenges to Non-surgical Perforation Repair 16317.2 Factors that Enhance Positive Long-Term Prognosis for Perforation Repair 16417.3 Surgical Perforation Repair Techniques 16617.4 Surgical Treatment for External Root Resorption 168Suggested Readings 17718 Intentional Replantation 179David Li and Samuel Kratchman18.1 Armamentarium 17918.1.1 Success Rate 17918.1.2 Indications 17918.1.3 Replantation or Apicoectomy 17918.1.4 Extraction 18218.1.5 Extraoral Phase 18318.1.6 Storage Medium 18318.1.7 Replantation 18318.1.8 Splinting 18518.1.9 Postop Instructions 18618.1.10 Cone Beam CT Scan 18618.1.11 Repairing Procedural Mishaps 186Suggested Readings 19119 Guided Tissue Regeneration in Endodontic Microsurgery 193Garrett Guess and Samuel KratchmanSuggested Readings 20220 Implants versus Endodontic Microsurgery 205Frank Setzer and Syngcuk Kim20.1 Historical Perspective 20520.2 Benefits of Implants 20520.3 Long-Term Prognosis of Dental Implants 20520.4 Implant Complications 20620.5 Long-Term Prognosis of Endodontically Treated Teeth with Root End Surgery 20720.6 Conclusion 209Suggested Readings 21021 Prognosis of Endodontic Microsurgery 213Meetu Kohli and Euiseong Kim21.1 Best Available Evidence 21321.2 Parameters for Success: Clinical and Radiographic 2D 21421.3 Parameters for Success: “Penn 3D Criteria” for Assessing Healing on CBCT 21521.4 Reversal of Success 21521.5 TraditionalMethods 21721.6 Modern Technique versus the Complete Microsurgical Approach 21821.7 Root End Filling Materials 21821.8 Case Selection 21921.9 Resurgery 21921.10 Summary 219Suggested Readings 21922 Positioning 221Samuel Kratchman and Syngcuk Kim22.1 Armamentarium 221Suggested Readings 226Index 227