Microsurgery in Endodontics E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 342

Veröffentlichungsjahr: 2017

Beschreibung

Microsurgery in Endodontics provides the definitive reference to endodontic microsurgery, with instructive photographs and illustrations. * Provides a definitive reference work on endodontic microsurgery * Includes contributions from pioneers and innovators in the field of microsurgical endodontics * Describes techniques for a wide range of microsurgical procedures * Includes more than 600 instructive illustrations and photographs

Leseprobe

Microsurgery in Endodontics

Syngcuk Kim, DDS, PhD, MD(Hon)Samuel Kratchman, DMD

Associate Editors:

Bekir Karabucak, DMD, MSMeetu Kohli, DMDFrank Setzer, DMD, MS, PhD

This edition first published 2018

© 2018 John Wiley & Sons, Inc.

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Library of Congress Cataloging-in-Publication Data

Names: Kim, Syngcuk, editor. | Kratchman, Samuel, editor. | Karabucak, Bekir, editor. | Kohli, Meetu, editor. | Setzer, Frank, editor.

Title: Microsurgery in endodontics / edited by Syngcuk Kim, Samuel Kratchman ; associate editors, Bekir Karabucak, Meetu Kohli, Frank Setzer.

Description: Hoboken, NJ : Wiley, 2018. | Includes bibliographical references and index. |

Identifiers: LCCN 2017026730 (print) | LCCN 2017028087 (ebook) | ISBN 9781119403654 (pdf) | ISBN 9781119403661 (epub) | ISBN 9781118452998 (cloth)

Subjects: | MESH: Dental Pulp Diseases–surgery | Microsurgery–methods | Endodontics–methods

Classification: LCC RK351 (ebook) | LCC RK351 (print) | NLM WU 230 | DDC 617.6/342–dc23

LC record available at https://lccn.loc.gov/2017026730

Cover Images: (Main and top inset images) Courtesy of Drs. Syngcuk Kim and Samuel Kratchman; (Left inset image) Courtesy of Dr. Kaname Yokota; (Right inset image) Courtesy of Dr. Garrett Guess

Cover design by Wiley

This book is dedicated to our “PENN ENDO FAMILY”; those who were educated at Penn. Without their dedication and practice in their schools and offices this field would not be what it is today!

Contents

Contributors

Preface

Acknowledgements

1 The Dental Operating Microscope

1.1 Benefits of the Operating Microscope

1.2 Key Features of Operating Microscopes

1.3 Customizing a Microscope

Suggested Readings

2 Microsurgical Instruments

2.1 Examination Instruments

2.2 Incision and Elevation Instrument

2.3 Tissue Retraction Instruments

2.4 Osteotomy Instruments

2.5 Curettage Instruments

2.6 Inspection Instruments

2.7 Ultrasonic Units and Tips for Root End Preparation

2.8 Microplugger Instruments

2.9 Suturing Instruments

2.10 Miscellaneous Instruments

3 Medication-Related Osteonecrosis of the Jaw and Endodontic Microsurgery

Suggested Readings

4 Indications and Contraindications

4.1 Introduction

4.2 Surgical Success Dependent on Ability to Perform Ideal Protocols

4.3 Etiology Assessment through Examination and Treatment

4.4 Periodontal Considerations and Surgery

4.5 Influential Patient Factors

4.6 Condition of Previous Endodontic Treatment

Suggested Readings

5 Anesthesia and Hemostasis

5.1 Armamentarium

5.2 Presurgical Phase

5.3 Surgical Phase

5.4 Summary of Hemostatic Techniques in Endodontic Microsurgery

5.5 Postsurgical Phase

Suggested Readings

6 Flap Design in Endodontic Microsurgery

6.1 Armamentarium

Suggested Readings

7 Osteotomy

7.1 Armamentarium

7.2 Osteotomy

7.3 Intact Cortical Plate without a Radiographic Periapical Lesion

7.4 Intact Cortical Plate with a Periapical Lesion

7.5 Fenestration through the Cortical Plate Leading to the Apex

8 Root End Resection

8.1 Armamentarium

8.2 Root End Resection

8.3 Root End Resection: Steep Bevel versus Shallow Bevel

Suggested Readings

9 Inspection of the Resected Root Surface: Importance of Isthmus

9.1 Armamentarium

Suggested Readings

10 Ultrasonic Root End Preparation

10.1 Armamentarium

Suggested Readings

11 MTA and Bioceramic Root End Filling Materials

11.1 Mineral Trioxide Aggregate (MTA)

11.2 Bioceramics

11.3 MTA and Bioceramic Application During Apicoectomy

11.4 Other Types of Cements for Root End Filling

Suggested Readings

12 Flap Reposition and Suturing

12.1 Suture Removal

Suggested Readings

13 Periapical Wound Healing

13.1 Principles of Wound Healing

13.2 Healing after Apical Microsurgery

13.3 Incomplete Healing/Scar Formation

13.4 Evaluation of Healing after Apical Surgery

13.5 Healing Evaluation Using CBCT

Suggested Readings

14 Cone Beam Computed Tomography

14.1 How CBCT Works

14.2 Indications and Clinical Applications

Suggested Readings

15 Mental Nerve Management

15.1 Armamentarium

Suggested Readings

16 Maxillary Posterior Surgery, the Sinus, and Managing Palatal Access

16.1 Maxillary Premolars

16.2 Sinus Exposure

16.3 Maxillary First Molars

16.4 Second Molars

Suggested Readings

17 Surgical Root Perforation Repair

17.1 Possible Challenges to Non-surgical Perforation Repair

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

17.3 Surgical Perforation Repair Techniques

17.4 Surgical Treatment for External Root Resorption

Suggested Readings

18 Intentional Replantation

18.1 Armamentarium

Suggested Readings

19 Guided Tissue Regeneration in Endodontic Microsurgery

Suggested Readings

20 Implants versus Endodontic Microsurgery

20.1 Historical Perspective

20.2 Benefits of Implants

20.3 Long-Term Prognosis of Dental Implants

20.4 Implant Complications

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

20.6 Conclusion

Suggested Readings

21 Prognosis of Endodontic Microsurgery

21.1 Best Available Evidence

21.2 Parameters for Success: Clinical and Radiographic 2D

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

21.4 Reversal of Success

21.5 Traditional Methods

21.6 Modern Technique versus the Complete Microsurgical Approach

21.7 Root End Filling Materials

21.8 Case Selection

21.9 Resurgery

21.10 Summary

Suggested Readings

22 Positioning

22.1 Armamentarium

Suggested Readings

Index

EULA

List of Tables

Chapter 1

Table 1.1

Table 1.2

Table 1.3

Chapter 3

Table 3.1

Table 3.2

Table 3.3

Chapter 5

Table 5.1

Table 5.2

Chapter 19

Table 19.1

Chapter 21

Table 21.1

List of Illustrations

Chapter 1

Figure 1.1

Comparison of magnification ranges: loupes versus microscopes.

Figure 1.2

Comparison of ocular angles and viewing directions of loupes and microscope.

Figure 1.3

Key microscope features (Penn Dental Endodontic Clinic).

Figure 1.4

Variable focal distance adjuster (ZEISS Varioskop®; Penn Dental Endodontic Clinic).

Figure 1.5

Top of the line microscope with electrical zoom, fine focus, and magnetic arrest functions, 3-chip HD video camera (TRIO 610) attached to right documentation port (ZEISS PROergo; Penn Dental Endodontic Clinic, Surgical Suite).

Figure 1.6

Binoculars with diopters for parfocaling procedure (Penn Dental Endodontic Clinic).

Chapter 2

Figure 2.1

Endodontic microsurgical instrument setup: (a) KiS set from Obtura/Spartan (Fenton, MO) (Image courtesy of Obtura Spartan, Algonquin, IL © 2017); (b) Jet Microsurgical kit from B&L Biotech Co. (Fairfax, VA). The KiS set has titanium handles while the Jet set are grouped as follows: silver color (examination instruments); yellow (elevation instruments); blue (curettage instruments); green (retrofilling carrier and plugging instruments). (Courtesy of B&L BioTech.)

Figure 2.2

The tip of the microexplorer examination instruments, which can be used to search for a leak in a root end filling or to distinguish a canal or craze line from a microfracture line, and to point to the origin of a leak for explanation and documentation purposes (×16).

Figure 2.3

15C blade and microblade.

Figure 2.4

Elevation instruments. Enlarged view of the tips of soft tissue elevators.

Figure 2.5

Tissue retraction instruments (KimTrac) with various mouth widths and shapes from 8 to 14 mm. These retractors have the thinnest serrated blade available.

Figure 2.6

KimTrac-M5 retractor with a plastic protector.

Figure 2.7

The plastic protector could retract and protect the flapped gingival tissue and lower lip.

Figure 2.8

Enlarged views of serrated blade widths. Middle (B) is the KimTrac blade and A and C are KP retractor blades. The KimTrac blade width is one-third that of the KP retractor.

Figure 2.9

Kim/Pecora (KP) retractors. Left to right, KP 1, KP 2, KP 3, and KP 4 retractors.

Figure 2.10

A 45 degree surgical handpiece (a) is designed to irrigate the surgical site while ejecting air from the back of the handpiece, eliminating water splatter and air emphysema (b).

Figure 2.11

Curettage instruments.

Figure 2.12

Enlarged view of the specially designed minicurettes and mini-molt curettes.

Figure 2.13

Small round curette in action.

Figure 2.14

Larger elongated curette in action.

Figure 2.15

Sharp periodontal curette in action.

Figure 2.16

Size comparison of the modified rectangular micromirrors with a regular dental mirror.

Figure 2.17

Micromirror reflecting the entire surface of the resected root of teeth. (Courtesy of Dr. Kanayo Kon.)

Figure 2.18

KiS tips 1, 2 for anterior teeth and KiS 3, 4, 5, and 6 for posterior teeth (Image courtesy of Obtura Spartan, Algonquin, IL © 2017).

Figure 2.19

KiS 1 tip is 3 mm long and has an 80 degree angle. (a) The tip is coated with zirconium nitride. (b) Water from the irrigation port, bathing the tip.

Figure 2.20

Set of JETips: JETip 1B, JETip 1L, JETip 1R, and JETip 1S (Courtesy of B&L BioTech).

Figure 2.21

JETip with metal microprojection (enlarged view).

Figure 2.22

(a) JETips for bending that provides a customized tip angle; (b) retropreparation with a JETip.

Figure 2.23

Stropko irrigator/drier.

Figure 2.24

Small diameter (2 mm) microplugger in action.

Figure 2.25

Larger diameter (5 mm) microplugger in action.

Figure 2.26

(a) Castroviejo needle holder; (b) Laschal microscissors for microsuturing (Mt Kisko, New York).

Figure 2.27

(a) Large ball burnisher for condensation of large areas of root end fill; minirongeur for removing granulation tissue from the bone crypt; bone file to smooth the bone and root surface. (b) Large ball burnisher in action.

Chapter 3

Figure 3.1

Patient suffering from MRONJ exhibits exposed bone in the maxillofacial area that does not heal regardless of treatment. (Courtesy of Dr Jose F. Lazaro.)

Figure 3.2

Panoramic radiographs of patients suffering from MRONJ exhibit the extent of the disease. The exposed area can extend beyond the alveolar bone and render the jaws fragile and prone to pathologic fractures. (Courtesy of Dr Jose F. Lazaro.)

Figure 3.3

The bone can be probed through an intraoral or extraoral fistula in the maxillofacial region. (Courtesy of Dr Jose F. Lazaro.)

Chapter 4

Figure 4.1

Previously treated mandibular molar with a separated file. (a) Periapical radiograph; (b), (c), and (d) axial and coronal views. A distal root fracture was identified on CBCT images that the periodical preop radiograph did not show. Therefore, extraction was opted.

Figure 4.2

Mandibular second molar with combined periodontal and endodontic lesions. Diagnosic tests showed pulp necrosis. (a) Radiograph showing extent of distal bone loss. (b) After endodontic treatment, bony defect and periodontal probing did not improve, indicating that the defect was primarily due to periodontal disease.

Figure 4.3

Previously treated mandibular first molar with apical periodontitis with furcation involvement. Presurgical probing was within normal limits. (a) Periapical radiograph showing underfilled mesial canals and periapical radiolucency. (b) Intraoral picture showing periodontal involvement and periodontal probing detected after the flap was raised. (c) Osteotomy after root end resection and after cleaning of granulation tissue.

Figure 4.4

Apex of maxillary lateral incisor was resorbed due to misplaced bone tack used to stabilize the bone grafting membrane. (a) Preoperative radiograph showing apical periodontitis and a resorptive defect. (b) Bone tack was removed and root end surgery was performed. Root end and reporptive defect was filled with Bioceramic root repair material. (c) Two and a half year follow-up radiograph showing complete bone healing.

Figure 4.5

Coronal view of a maxillary molar showing apical periodontitis around the MB root. MB2 canal exits palatally at the mid-root area. More than 3 mm of root resection would be necessary to the exposed MB2 canal during surgical retreatment, but more than 3 mm of root resection would compromise the crown–root ratio. Therefore, non-surgical retreatment should be considered.

Figure 4.6

(a) Mandibular molar with deep periodontal probing around the distal root. (b) Bony defect showing advanced periodontal involvement. Prognosis is guarded due to furcation bone loss.

Figure 4.7

Poor quality prior endodontics that can be improved upon utilizing current techniques and technologies.

Figure 4.8

Poor quality and inadequate restoration may cause coronal leakage. Non-surgical retreatment with a new coronal restoration should be performed to treat apical periodontitis. (a) Periapical radiograph showing apical radiolucency and inadequate coronal seal. (b) Postoperative radiograph. (c) Six month follow-up radiograph showing complete resolution of apical radiolucency.

Figure 4.9

Persistent infections outside the root may not be healed by non-surgical retreatment. Periradicular lesion should be surgically removed and should be submitted for pathological evaluation. (a) Intraoral picture showing osteotomy site and tissue removal for biopsy. (b) Biopsy report confirming actinomycosis.

Figure 4.10

Previously treated maxillary first molar. Periapical radiograph showing separated instrument within the curved apical area of the MB canal. Surgical retreatment should be opted to preserve tooth structure and prevent any possible procedural errors during removal of the separated instrument.

Chapter 5

Figure 5.1

DentalVibe device (DentalVibe Inc., Boca Raton, Fl.).

Figure 5.2

Use of DentalVibe in palatal infiltration.

Figure 5.3

STA single tooth anesthesia system (Milestone Scientific, Livingston, NJ).

Figure 5.4

Maxillary anterior injection. Anesthetized area and teeth are shown in gray.

Figure 5.5

Maxillary posterior area injection. Anesthetized area and teeth are shown in gray.

Figure 5.6

Mandibular anterior area injection. Anesthetized area and teeth are shown in gray.

Figure 5.7

Mandibular posterior area injection. Anesthetized area and teeth are shown in gray.

Figure 5.8

Racellet epinephrine containing pellet (Pascal International, Bellevue, WA).

Figure 5.9

Several hemostatic Racellets packed in the osteotomy site and pressure applied for about 2–3 min.

Figure 5.10

Hemostatic pellets removed one by one from the osteotomy site; last one left in for continuous hemostasis.

Figure 5.11

Ferric sulfate used for hemostasis on persistent small bleeders during the surgery: (a) 21% ferric sulfate (GingiPak, Camarillo, CA); (b) ferric sulfate being applied with a small cotton pellet.

Figure 5.12

Ecchymosis: (a) 4 days after surgery; (b) 1 week after surgery; (c) 3 weeks after surgery.

Chapter 6

Figure 6.1

Current flap designs in endodontic microsurgery: (a) submarginal rectangular flap; (b) submarginal triangular flap; (c) sulcular rectangular flap; (d) sulcular triangular flap.

Figure 6.2

The presence of full ceramic crowns on two anterior teeth indicates the need for a submarginal rectangular flap.

Figure 6.3

The horizontal submarginal incision is carried out within the attached gingiva (red line indicates the incision; gray line represents the mucogingival border). The vertical releases are aligned parallel and must never be wider at the base to avoid scarring and allow proper blood supply for all surrounding soft tissues.

Figure 6.4

Sequence of soft tissue healing after a submarginal triangular flap for microsurgery on a right maxillary lateral incisor: (a) preoperative radiograph; (b) preoperative clinical situation; (c) incision; (d) sutures. (e) Suture removal 3 days postoperatively; (f) 2 week follow-up; (g) 8 week follow-up.

Figure 6.5

Sulcular triangular flap in preparation for surgery on a first mandibular molar.

Figure 6.6

Sequence of soft tissue healing after a sulcular incision for microsurgery on a maxillary first molar: (a) preoperative clinical situation; (b) incision; (c) sutures; (d) suture removal 3 days postoperatively; (e) 8 week follow-up; (f) 1 year follow-up; note that no clinical signs of gingival recession are present.

Figure 6.7

For a sulcular incision, the vertical incision joins the horizontal incision lateral to the papilla base at a 90 degree angle.

Figure 6.8

15C Bard-Parker blade.

Figure 6.9

Microblade indicated in the esthetic zone or in the presence of poorly keratinized tissue.

Figure 6.10

Incision of thin or poorly keratinized tissue using a microblade.

Figure 6.11

Sequence of soft tissue elevation.

Chapter 7

Figure 7.1

Use of CBCT: (a) a sagittal view from a CBCT image of tooth #19 measuring the distance from the mental foramen; (b) a coronal view from a CBCT image of tooth #19 measuring the distance from buccal plate to the lingual surface of the root; (c) an axial view from a CBCT image of tooth #19 measuring the distance from the buccal plate to the lingual surface of both mesial and distal roots.

Figure 7.2

A 45 degree surgical handpiece (Brasseler, USA) with a Lindemann bone cutter bur.

Figure 7.3

Osteotomy: (a) a small initial osteotomy and root tip are hardly visible at ×2; (b) the root has a darker, yellowish color, and is hard, whereas the bone is white; (c) root tip is clearly visible.

Figure 7.4

Apical fenestration. The root tip is sticking out of the cortical bone.

Figure 7.5

Comparison of osteotomies made with standard surgical instruments (left, ×1) and microsurgical instrument (right, ×10). The new techniques result in a significantly smaller osteotomy.

Figure 7.6

The ideal osteotomy is no larger than 4 mm in diameter to accommodate the 3-mm long ultrasonic tip in the bone crypt. The osteotomy is small but large enough to accommodate the ultrasonic tip.

Figure 7.7

Ultrasonic tips of varying lengths: 3 mm, 6 mm, and 9 mm.

Figure 7.8

(a) Schematic drawing that illustrates the key hole osteotomy modification to accommodate the longer tip without enlarging osteotomy size. (b) Key hole modification on an osteotomy for the mesial root tooth #30. The key hole modification will allow the ultrasonic tip to approach the roots without excessively sacrificing any extra bone structure. (Figure 7.8b and c are courtesy of Dr Kaname Yokota.)

Figure 7.9

W&H Piezome instruments. Fine-toothed saw for fine cuts with 8 mm and 10 mm depth, with little bone loss when harvesting bone blocks.

Figure 7.10

A rectangular window is cut in the buccal cortical plate using Piezomed instruments. Two holes were made to facilitate blood circulation during healing.

Figure 7.11

The removed bone window is stored in HBSS solution until the end of the procedure.

Figure 7.12

Step by step bone window procedure: (a) bone saw preparing window; (b) bone window completed; (c) bone window being removed; (d) granulation tissue exposed; (e) ultrasonic preparation of resected root tip; (f) Bioceramic root end filling. (g) Bone window being replaced; (h) bone window replaced wedging in collagen membrane; (i) two collagen membranes placed over the bone window; (j) sutures placed; (k) pre operative radiograph; (l) post operative radiograph; (m) three year recall radiograh.

Chapter 8

Figure 8.1

Granulation tissue is removed to the extent where the root apex is clearly identified.

Figure 8.2

3 mm of the root end of tooth #6 is resected (magnification ×10). (Courtesy of Dr Francesco Maggiore.)

Figure 8.3

Removal or the apical 3 mm end of the root eliminates 98% of the apical ramifications and 93% of the lateral canals.

Figure 8.4

Central incisior with extruded gutta percha. (a) Preoperative radiograph of tooth #9 with guttapercha overfilling. A 3 mm root end resection would be at the level of the post. Therefore, 1.5 mm of the root tip is resected. (b) Postoperative radiograph showing MTA root end filling. (c) Radiograph taken 6 months after treatment, revealing complete bone healing.

Figure 8.5

Periapical surgery on tooth #7. After methylene blue staining, the PDL appears as an uninterrupted circular line around the root surface (magnification ×16).

Figure 8.6

Periapical surgery on tooth #19. (a) Partial root resection of the mesial root (magnification ×8). (b) The resected root surface is stained with methylene blue and inspected. The outline of the periodontal ligament (PDL) is disrupted on the lingual aspect of the root. Also, only the buccal canal is stained. Further resection in a lingual direction is needed (magnification ×16). (c) Direct view of the root end filling shows the complete circumference of the root (magnification ×16).

Figure 8.7

Incomplete root resection seen at 1 and 2.

Figure 8.8

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).

Figure 8.9

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.

Figure 8.10

Periradicular surgery on tooth #30. The angle of root end resection of the mesial root is 5 degrees to facilitate the direct view of the resected surface under the microscope and the distal root is 0 degrees, perpendicular to the long axis of the tooth.

Chapter 9

Figure 9.1

Stropko irrigator with an attached blunt needle: (a) Stropko irrigator; (b) schematic drawing of the drying of the root surface.

Figure 9.2

Staining of the resected surface of the mesial root of tooth #19 with 1% methylene blue in order to facilitate inspection (magnification ×10).

Figure 9.3

During inspection, the micromirror is placed at 45 degrees to the resected surface and the reflected view of the root surface shows every anatomical detail of the canal system. A high magnification of the microscope is used at ×14 to ×26.

Figure 9.4

Inspection is done under a high magnification of the microscope (×16 to ×26). (a) Missed lingual canal and unprepared isthmus; (b) vertical root fracture; (c) multiple accessory canals; (d) unfilled isthmus; (e) missed buccal canal.

Figure 9.5

Inspection reveals obvious reasons for failure of the endodontic treatment (magnification ×16 to ×26). (a) Missed middle mesial canal and unprepared isthmus; (b) canal transportation; (c) a gap in the filling.

Figure 9.6

“Frosted” dentine on the buccal segment of the resected surface of an upper second premolar. Frosted dentine is always demarcated by craze lines.

Figure 9.7

Various types of isthmuses are seen in all teeth resected root surfaces (magnification between ×16 and ×24). (g) Inspection after 3-mm root resection of the mesial root revealed a long type V isthmus (black arrows) (magnification, ×16); (h) root end filling with MTA (magnification, ×16); (i) postoperative radiograph; (j) 6 month recall radiograph; (k) 1 year recall radiograph showing complete healing of the lesion. (Case courtesy of Dr Helmut Walsh.)

Figure 9.8

Types of isthmuses: type I, two or three canals with no noticeable communication; type II, 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; type IV are canals that extend into the isthmus area; type V, a true connection or corridor throughout the section.

Figure 9.9

At the 3- and 4-mm level from the apices of the mesiobuccal roots of maxillary first molars, a complete (type V) or partial (type IV) isthmus was present 90% and 100% of times, respectively. (Modified from Weller

et al.

,

J Endod

1995.)

Figure 9.10

A histological examination of the resected root surface where an isthmus is found revealed a huge concentration of bacteria and its byproducts. (Courtesy of P.N.R. Nair.)

Figure 9.11

A histological examination of the resected root surface where an isthmus is found revealed a huge concentration of bacteria and its byproducts and another one of instrumented canals and a cleaned isthmus. (Courtesy of Ricucci and Vera, reproduced by permission.)

Figure 9.12

Amalgam placed as a root end filling material on a previous failed surgery done with the traditional technique on tooth #30. Non-surgical retreatment was performed, but periapical lesion persisted. A second apical surgery using microsurgical technique was done and the periapical pathology was eliminated. It is obvious that the cause of the persistent periapical lesion was a long, type V isthmus. (a) Preoperative radiograph; (b) non-surgical retreatment; (c) 6 month recall radiograph; (d) 1 year recall radiograph; (e) 2 year recall radiograph showing persistence of the periapical lesion on the mesial root; (f) preoperative radiograph of the second periapical surgery. (g) Inspection after 3-mm root resection of the mesial root revealed a long type V isthmus (black arrows) (magnification, ×16); (h) root end filling with MTA (magnification, ×16); (i) postoperative radiograph; (j) 6 month recall radiograph; (k) 1 year recall radiograph showing complete healing of the lesion. (Case courtesy of Dr Helmut Walsh.)

Chapter 10

Figure 10.1

The ideal root end preparation can be defined as a Class I cavity at least 3 mm into root dentine after the apical root tip of 3 mm is resected, with walls parallel to and within the anatomic outline of the root canal space.

Figure 10.2

Preparation with an old microhandpiece. (a) Histological images of root end preparations in dog teeth by a bur (left) and ultrasonic tip (right). The bur preparation nearly resulted in a lingual perforation, while the ultrasonic preparation preserved the integrity of the root apex and remained along its long axis. (b) and (c) Preparation with a bur ends up in a dome-shaped preparation rather than a Class I cavity preparation and therefore retention of the root end filling material is compromised.

Figure 10.3

Root end preparation during surgery on a tooth. (a) Proper alignment of the tip, coaxial with the root, is done at a low magnification of the microscope before preparation starts MB canal; (b) ML canal; (c) ultrasonic preparation begins on ML canal; (d) final view with MB, ML, DB, DL root end preparations sealed with Bioceramic putty. (Courtesy of Dr Kaname Yokota.)

Figure 10.4

Schematic drawing showing an off-angled preparation resulting from wrong angulation of the ultrasonic tip alignment. This mistake sometimes results in lingual perforation.

Figure 10.5

Schematic drawing showing ideal root end preparation when the ultrasonic tip is aligned along the long axis of the root.

Figure 10.6

Radiographic appearance of two root end preparations. The mesial root end preparation was done at a wrong angle. The distal preparation was done following the long axis of the root.

Figure 10.7

Apical surgery on the mesial root of tooth #19. (a) Preoperative radiograph showing calcified mesial canals; (b) inspection revealed complete obliteration of the mesial canals and isthmus due to calcification (magnification ×16); (c) root end preparation was done (magnification ×16); (d) Postoperative radiograph shows that preparation and root end filling are coaxial with the canals.

Figure 10.8

Tooth #7: (a) root end preparation on tooth #7 (magnification ×16); (b) when root end preparation is done in the correct direction, gutta percha is “walking” out of the preparation (magnification ×16).

Figure 10.9

Inspection of root end preparation. (a) A small part of gutta percha is left (arrow) on the buccal wall of the prepared root end cavity. (b) In order to remove this excess gutta percha, the ultrasonic tip can be angled buccally so that the end of the tip will vibrate against the facial wall and gradually loosen the remaining filling material.

Figure 10.10

Prepped canals. (a) Perfectly prepared single root both in angle and depth reflected on a micromirror. (b) There are two apices next to each other; preparation at the correct angle and depth.

Chapter 11

Figure 11.1

Dog root apex filled with ProRoot MTA: (a) histology slide; (b) micro CT.

Figure 11.2

SEM pictures of MDPC 23 cells on (a) plastic plate. (b) and (c) ProRoot MTA; high magnification of cell grown on ProRoot MTA.

Figure 11.3

Periapical radiographs taken after apical surgeries on bilateral premolars in canine. Top: root end cavities were randomly filled with RRM (R) and MTA (M) while the root canals remained infected. Bottom: X-ray after 6 months of healing. All roots demonstrated complete healing using Rud's and Molven's criteria.

Figure 11.4

Periapical tissue response in root filled with EndoSequence Root Repair Material. (a) Overview of cross-section: re-establishment of buccal cortical plate and periapical tissue reformation. (b) Magnified view of the root end surface. No inflammatory cells were found in the periapical area near the exit of the root canal. RRM remnant in periapical tissue did not induce inflammatory reaction (yellow arrow). Cementum-like tissue formed on the resected root end surface and RRM root end filling (green arrow) with fibrous insertion from the adjacent PDL-like tissue.

Figure 11.5

PDL stem cells attach and spread well on the surface of RRM, suggesting the material is biocompatible.

Figure 11.6

Use of MTA block. MTA block was designed by cutting grooves into a 0.5 inch × 0.5 inch × 2 inch plastic block. (a) Mixed MTA is filled into a groove of the MTA block. (b) and (c) Small amount of MTA pellet is scooped out of the grooves using a carrier.

Figure 11.7

Clinical presentation of the root end filling procedure using Bioceramic RRM. (a) Inspection of the resected root surface at high magnification; (b) inspection of the root end preparation in order to ascertain clean walls; (c) placement of Bioceramic RRM with a carrier; (d) condensation of the material with plugger; (e) cleaning of the resected root surface with a wet cotton pellet; (f) inspection of the root end filling material to ensure well-adapted margins.

Figure 11.8

Bioceramic putty can be rolled to form a cylinder with the desired diameter. The operator can use MTA carrier to pick up the adequate length of Bioceramic and place it into the root-end cavity.

Chapter 12

Figure 12.1

(a) Continuous sling suture. (b) Single knot, interrupted suture.

Figure 12.2

Sequence illustrating a continuous sling suture.

Figure 12.3

Sequence illustrating a single knot, interrupted suture.

Figure 12.4

A triangular submarginal flap was raised to reach and curettage the apical third of tooth #5. (a) Preop radiograph; (b) pre-operative presentation of the soft tissue; (c) incision; (d) flap elevation; (e) to (h) synthetic monofilament 6.0 sutures, where knots are not tied on the incision line; (i) to (l) sutures removed after 72 hours. (m) and (n) 2 month follow-up; (o) and (p) 4 month follow-up. The incision line not visible.

Figure 12.5

Apical surgery of a maxillary left canine. (a) Preop radiograph; (b) submarginal incision; (c) flap raised and endo-osseus implant visible; (d) exploration of the resected root surface under high magnification (×20); (e) ultrasonic preparation; (f) and (g) metal object removed; (h) retropreparation complete; (i) MTA root end filling; (j) postop radiograph; (k) and (l) 7.0 monofilament sutures. (m) to (p) Sutures removed at 48 hours; (q) and (r) 6 month follow-up. (s) 1 year follow-up; (t) and (u) 3 year follow-up; (v) and (w) 10 year follow-up.

Chapter 13

Figure 13.1

Three basic phases of wound healing: inflammation, proliferation, and remodeling.

Figure 13.2

Wound healing after apical microsurgery: apical dentoalveolar healing and osseous healing.

Figure 13.3

Wound healing after apical microsurgery: The cavity is filled with a coagulum that will become replaced by granulation tissue. The formation of new bone begins from internally and progresses externally towards the level of the original cortical plate. When newly laid woven bone reaches the lamina propria, the overlying membrane turns into functional periodontium.

Figure 13.4

Incomplete healing (scar tissue) after endodontic surgery. The sunburst appearance is due to bone trabeculae radiating from the center of the defect that remained radiolucent. (a) A 10 month follow-up; (b) a 17 month follow-up.

Figure 13.5

Example of complete healing after endodontic microsurgery: CBCT analysis and 2.5 year follow-up of maxillary first molar. (a) Sagittal view; (b) axial view; (c) coronal view.

Figure 13.6

Comparison of two-dimensional (2D) versus three-dimensional (3D) analysis after surgery on the distal root of a first right mandibular molar: (a) preoperative radiograph; (b) postoperative radiograph; (c) 1 year follow-up, classified as uncertain healing according to Molven's criteria (2D); (d) 1 year follow-up CBCT sagittal view, classified as limited healing according to PENN 3D Criteria (note that the complete bone fill within the previous osteotomy is in direct contact with the resected root surface and root end filling material, but is of lower bone density in comparison to the original mature bone surrounding the osteotomy); (e) axial view (3D); (f) coronal view (3D).

Figure 13.7

CBCT analysis of endodontic microsurgery on a first right mandibular molar, mesial root. (a) Preoperative coronal view; note the prominent buccal position but absence of fenestration. (b) A 1 year follow-up coronal view. Note the complete cover of the resected root surface by newly formed bone, but the low density area is inferior to the layer of bone and does not show bone reformation. This is limited healing according to PENN 3D Criteria.

Chapter 14

Figure 14.1

Previously treated mandibular first molar with apical periodontitis. (a) Periapical radiograph shows well-filled root canals and well-fitted crown restoration with a post in the distal canal. (b) Sagittal view showing large low-density area around the mesial root. (c) Axial view showing a well-defined, large low-density area limited to the mesial root. The buccal cortical bone is thick and intact. (d) Coronal view showing a thick buccal cortical bone and the location of the mesial root. Distance from the buccal cortical bone to the end of the mesial root exceeds the length of a Lindemann surgical bur and may limit full root resection. Therefore, non-surgical retreatment was chosen.

Figure 14.2

Previously treated maxillary lateral incisor with apical periodontitis. (a) Periapical radiograph showing crown restoration and root canal filling. Apical radiolucency is visible on the radiograph. (b) Sagittal view confirms apical sharp curvature. Root canal filling is not following the apical curvature. (c) Sagittal view showing a larger low-density area compared to periapical radiograph. Due to severe apical curvature, surgical retreatment was chosen.

Figure 14.3

Previously treated mandibular molar. Tooth was asymptomatic. Patient was referred for possible endodontic treatment. (a) Periapical radiograph showing apical radiolucency around the mesial root. (b) Coronal view shows mesial root anatomy. Axial and sagittal views showing unusual mental foramen anatomy with two exits. Endodontic treatment was not necessary.

Figure 14.4

Previously treated mandibular premolar. (a) Periapical radiograph showing apical pathology. The tooth was restored with a PFM crown. (b) CBCT images show lesion associated with the tooth and close proximity to the mental foramen. Due to the location of the mental foramen non-surgical treatment was chosen.

Figure 14.5

Cases representing sinus exposure, mandibular nerve, and mental foramen. (a) Previously treated maxillary first molar. Patient was symptomatic. Patient's medical history revealed previous sinus surgery. Preoperative radiograph showing previous root canal treatment and extruded filling material from the mesial canal. (b) Coronal view showing missed MB-1 canal, extruded material in maxillary sinus, and sinus perforation at the previously surgerized site; (c) Postoperative radiograph. Due to missed MB canal, non-surgical retreatment was opted for. (d) CBCT 3D rendering, showing buccal cortical perforations and the site of previous sinus surgery. (e) Due to patient's persistent symptoms, surgical retreatment was planned. Intraoral picture showing exposed sinus from a previous sinus surgical site. (f) Postoperative radiograph showing resected MB root and root end fillings. (g) Periapical radiograph showing mandibular molar with a separated instrument and large radiolucent area. Due to the location of the separated instrument and the size of lesion, a surgical approach was opted for. (h) Sagittal view showing a large low-density area including the mandibular nerve. (i) Coronal view showing the extent of lesion around the mesial root. (j) Coronal view showing the extent of lesion around the distal root. (k) Surgical pictures showing the extent of lesion and exposed mandibular nerve. (l) Postsurgical radiograph showing resected mesial and distal roots with root end fillings. (m) Periapical radiograph showing the mandibular premolar with apical radiolucency. The tooth was previously treated and restored with a well-fitted PFM crown and post. (n) and (o) CBCT images showing the close proximity of the mental nerve to the root end. Intentional replantation was chosen. (p) Postreplantation radiograph showing root end resection with root end filling.

Figure 14.6

Periapical radiograph showing the mandibular second molar. An attempt to locate calcified canals was unsuccessful. Intentional replantation was chosen. (a) Preop radiograph. (b) Coronal view showing apical curvature rotating towards buccal. Curved roots cause difficulty during extraction, resulting in root fracture. With the information obtained from CBCT, the tooth was rotated towards buccal and removed without damaging the root. (c) Postoperative radiograph showing successful replantation of the tooth, root resection, and root end filling.

Figure 14.7

Lower molar with Radix Entomolaris. (a) Radiograph showing previously treated mandibular first molar with apical radiolucency. (b), (c), and (d) Axial view confirming low-density area only around the additional distolingual root. Distance between the buccal cortical bone to radix was measured on axial and coronal views. Images confirmed that the distolingual root can be reached. Therefore, surgical retreatment was opted for. (e) Distolingual root was resected and root end filling was placed. (f) Postoperative radiograph showing root end resections and fillings.

Figure 14.8

Previously treated maxillary first molar with apical periodontitis. (a) Periapical radiograph showing a large radiolucent area around mesial and distal roots, separated instrument in the distal canal, and apical transportation of the MB root. (b), (c), and (d) CBCT images showing a large low-density area extending into the furcation area and postperforation in the palatial root.

Figure 14.9

Palatal surgery maxillary right first molar. (a) Radiograph showing maxillary first molar requiring root canal treatment. (b) CBCT images showing a large low-density area around the palatal root and resorbed apex of the palatal root. (c) Postop palatal apico. (d) One year follow-up. (e) One year follow-up CBCT images of the surgical site showing cortical bone healing and reconstitution of PDL space.

Figure 14.10

Previously treated maxillary first molar with furcation involvement. (a) Periapical radiograph showing periradicular radiolucency extending into the furcation area. (b) and (c) CBCT images showing apical and furcation low-density areas. Furcation perforation and a previous repair attempt were identified on CBCT scans. (d) and (e) Intraoral pictures showing furcation perforation and second repair with a Bioceramic putty. (f) Postoperative radiograph showing successful root canal treatment with furcation perforation repair.

Figure 14.11

Palatal resorption. (a) CBCT images showing a maxillary incisor with palatal cervical resorption. (b) Intraoral pictures showing cervical resorptive defect and repair with Geristore. (c) Postoperative radiograph showing root canal treatment with coronal and cervical fillings.

Figure 14.12

Cervical resorption. (a) Periapical radiograph showing the maxillary right incisor with cervical radiolucency indicative of resorption. (b) Axial view. (c) Coronal view shows advanced external root resorption. Due to the extent of the resorptive defect, endodontic treatment could not be performed.

Figure 14.13

Previously treated maxillary central incisor with a large post and root resorption. (a) Preop radiograph. (b) CBCT images showing buccal mid-root root perforation with denuded buccal cortical bone. (c) and (d) Intraoral pictures showing the resorptive defect and the repair with Bioceramic root repair material. Due to the location of the bone defect and intact apical bone, apical resection was not performed. (e) Postoperative radiograph. (f) One year follow-up radiograph. (g) Coronal view showing cortical bone healing around the root repair material at 1 year follow-up. (h) axial view showing cortical bone healing around the root repair material at 1 year follow-up.

Figure 14.14

Diagnosis maxillary first molar. (a) Periapical radiograph showing maxillary first molar requiring root canal treatment (b) and (c) CBCT images showing palatal root fracture that could not be identified on periapical radiograph.

Figure 14.15

Maxillary canine with previous apicoectomy. (a) Periapical radiograph showing a previously surgerized maxillary canine. Previous root end surgery was unsuccessful. (b) Coronal view. (c) Intraoral image shows previous root resection with root end filling. The root end was not resected completely and the root end filling was inadequate to seal the root canal. (d) Root resection was corrected. (e) Postsurgery radiograph showing sealed root end. (f) Eight month follow-up.

Figure 14.16

Trauma to maxillary central incisor of 9 year old patient. (a) Radiograph showing horizontal root fracture located at the apical third of tooth. (b) and (c) CBCT images showing the extent of root fracture. The tooth will need to be extracted as opposed to just observation.

Figure 14.17

Symptomatic, previously treated maxillary lateral incisor. (a) Due to a long post and well-fitting crown, surgical treatment was planned. (b) Postsurgical radiograph showing root resection and root end filling. (c) A 5.5 year follow-up radiograph. (d) A 5.5 year CBCT shows complete apical and cortical bone healing and reconstitution of PDL.

Chapter 15

Figure 15.1

Mental nerve bundle exiting the mental foramen.

Figure 15.2

The mental foramen is frequently located by the apex of the second mandibular premolar or between the apices of the premolars.

Figure 15.3

Accessory mental foramina (AMF). (a) Large AMF. (b) Small AMF in the surrounding area of the mental foramen that tends to exist in the apical area of the first molar and posterior or inferior area of the mental foramen.

Figure 15.4

Periapical film showing the mental foramen.

Figure 15.5

A Panorex film showing the mental foramina.

Figure 15.6

CBCT shows coronal, sagittal, and axial views of the mandibular right posterior area, and a clear view of the mental foramen.

Figure 15.7

CBCT of #29. (a) Clear view of the mental foramen. (b) Arrows point to the apex of the root and the mental foramen. This distance is average.

Figure 15.8

CBCT of #20. (a) Coronal view of #20. Note the closeness of the mental foramen with the apex. (b) Axial view showing the entrance of the mental through the buccal cortical bone.

Figure 15.9

Area for the pricking test to assess the degree of paresthesia.

Figure 15.10