SEMINAR TOPIC

ENDODONTIC SURGERY
WITH FOCUS ON
MAGNIFICATION &
ILLUMINATION
PRESENTED BY-
DR. RAGHAV AGRAWAL
2ND YEAR PG
DEPARTMENT OF CONSERVATIVE DENTISTRY & ENDODONTICS
 CONTENTS
 ENDODONTIC SURGERIES
 INTRODUCTION
 HISTORY
 CLASSIFICATION
 INDICATION
 CONTRAINDICATION
 STEPS OF ENDODONTIC SURGERY
 ENDODONTIC MICROSURGERY
 MAGNIFICATION
 DENTAL LOUPES
 DENTAL OPERATING MICROSCOPES (DOM)
 ILLUMINATION
 MICROSURGICAL INSTRUMENTS
 DIFFERENCE BETWEEN TRADITIONAL & MICROSURGICAL ENDODONTIC SURGERY
 SOFT TISSUE MANAGEMENT
 INTRODUCTION
 FLAP DESIGN & PREPARATION
 RULES OF FLAP DESIGN
 ARMAMENTARIUM
 CLASSIFICATION OF SURGICAL FLAPS
 INCISION
 ELEVATION
 RETRACTION
 SUTURE
 POST OPERATIVE INSTRUCTIONS
“At a given instant everything the surgeon knows suddenly becomes
important to the solution of the problem. You can’t do it in an hour
later, or tomorrow. Nor can you go to the library and look it up.” –
John W. Kirklin (American Cardiothoracic surgeon)
 ENDODONTIC SURGERIES
 The term surgery is derived from the Greek word ‘Cheir’ (Hand) ‘Ergon’ (to work), and from the latin
word ‘Chirurgia’ “treatment of disease, injury or deformity by manual or instrumental operations, as
the removal of diseased parts of tissue by cutting.
 Endodontic surgeries was once thought to be a therapy of last resort.
 But now a days the advancements in recent years has helps the clinician’s ability to achieve more
predictable and successful clinical outcomes.
 The success rate of surgical endodontics is high, about 73–99%, depending on the criteria used for
evaluating success.
 Endodontic Surgery – encompasses surgical procedures performed to remove the causative agents of
radicular and periradicular disease and to restore these tissues to functional health.
 Currently, endodontic surgery falls into more than one domain and is a predictable and integral part of
comprehensive endodontic services.
 The expanded scope of endodontic surgery includes apical curettage, apicoectomy, root-end resection
with root-end filling, hemisections, replantations, transplantations, and guided tissue regeneration, with
more advances on the horizon.

Fig 1 : Apical Curettage

Fig 2 : Apicoectomy followed by root

resection with root-end filling
 Fig 3 : Hemisection

Fig 4 : Bicuspidization
Fig 5 : Replantation Fig 6 : Transplantation
 Fig 7 : Guided Tissue Regeneration

 Four major areas of surgical endodontics are – surgical drainage, radicular surgery, replacement
surgery and implant surgery.
 These areas may have certain basic similarities but have considerate differences as well as in terms of
indications & techniques, which should be well known to the endodontics.
 Late Dr. Irwing J Naidorf quoted, that “ A good surgeon knows how to cut, a better surgeon knows
when to cut and the best surgeon knows when not to cut.”
 HISTORY

 1500 years ago the first recorded surgical endodontic procedure of incision and drainage of an acute
abscess was performed by Aetius, a Greek physician dentist.
 Since then surgical endodontics has been developed and refined as a result of valuable contributions of
many pioneers in dentistry Abilcasis, Fauchard, Hullihan, Martin, Partisch and Black.
 Dr. Louis I. Grossman, dean of endodontics in America, has contributed significantly to the science of
endodontics and has divided the 200 years between 1776 and 1976 into four periods, and each period
consist of fifty years duration.
 Some of the important events are mentioned as follows :
1st PHASE (1776-1826) :
 Robert Woffendale, 1783 - Principles of cauterization and use of cautery.
 Joseph Fox, 1778 - Recommended transplantation of single rooted teeth in his book , “The Natural
History of the Human Teeth”
 James Gardelte, 1850 - Proposed intentional replantation of teeth, for the first time in the history of
dentistry.

2nd PHASE (1826-1876) :

 Sanford C. Barnum, 1864 – Introduced Rubber dam.
 Harris, 1839 - Proposed use of a ‘lancet or sharp pointed knife to evacuate pus from a tumor of
gums. 
 Adolph Witzel, 1874 - Described an operation for mummification of pulp.
 W.H. Atkinson, 1850 - Suggested the use of sulphuric acid to burnout the fistula.
3rd PHASE (1876-1926) :
 William Hunter, 1910 – Gave Focal infection theory, which came as ‘black eye blow’ to the science
of endodontic surgery as it led to wholesale extraction of pulpally involved teeth. It was encouraged
by medical profession as a treatment of variety of illness, but was a setback to endodontics.
 Claude Martin, the father and the inventor of root end resection, 1881 - Used this technique to
manage teeth with draining sinus tracts.
 Farrar, 1884 - Recommended root end resection.
 G.V. Black, 1886 - Recommended amputation of the apex of the root of any teeth in the case of
long neglected abscesses.

Fig 8 : Root
resection as
advocated by G.V.
Black
 Actual root end resection is often identified with pre Columbian dentistry practiced in Ecuador by
Saville, who discovered a skull with a tooth which was implanted and gave every indication of
resection of the apical portion of the root.
 In the middle of 18th century the root end fillings placed after resection were usually wax, lead or
gold.
 Brophy, 1880 – Provided a report on root end resection with immediate root canal fill and
management of the apical filling.
 Ottolengui, 1892 - Presented a succinct technique for immediate filling of root canal followed by
resection of root apex.
 Between 1893 to 1900 in Germany, Carl Partisch proposed “Wurzelspitzenresection” i.e. root end
resection under “Chloroformnarkose” i.e. chloroform. He used a vertical incision with iodoform
packing technique for the procedure.
 Magitot, 1867 – First performed complete root removal or root resection.
 White and Younger, 1893 - Recognized the need to remove roots in their entirety that were plagued
with “pyorrhea alveolaris”.
 Fig 9 :
a. Palatal root exhibiting extensive
“pyorrhea alveolaris”.
b. Tooth following root resection and
osseous repair.

 Beal, 1908 - Contributed towards development of endodontic surgery in France by publishing

several articles and techniques on “root apex resection”. 
 Neumann, 1915 - Focused on lower molar surgery.
 Otto Hofer, 1935 – Provided a thorough review of surgical flap designs for purpose of endodontic
surgery and Partisch proposed soft tissue management and techniques for cyst management.
 Ross in this era was first to indicate the use of amalgam as root-end filling material.
 Fig 10 : Diagrammatic
representation of placement of
amalgam as root end filling
material to block all the open
dentinal tubules to prevent them
from reinfection

4th PHASE (1926-1976) :

 This period was marked by the renaissance of endodontic treatment.
 Attention on surgical armamentarium was at its peak.
 Killian headband were introduced, which was used for root end resection, coupled with surgical
shield, suggested by Witzel in conjunction with the headband.
 Fig 11 : Patient wearing Killian
headband, modified for use with
periapical surgery.

 Berger, Ruggier, Moorhead, Kay and Posner advocated semilunar flaps as a particular way of flap
reflection, with triangular flaps beginning to appear. Also the use of mallet and chisel for root end
 Fig 12 : a. Semilunar Flap b. Triangular Flap
 Blayney and Wach, 1924 – Published an article on a study that they conducted to prove that new
cementum deposition and periodontal healing were possible on the surface of resected dentin. 
 Dr. Fernando Garcia, 1935 – Proposed the use of zinc oxide eugenol as root end filling material
for the first time.
 Cyrus Jones between 1941 and 1950 – Recommended one visit root canal fill followed by surgical
curettage. He also used chloroform at the apex to soften and dissolve the excess gutta-percha making
a perfect joint. 
 Also, during this period more attention was focused on surgical curettage and total eradication of the
soft tissue surrounding the root. 
 Messing, 1958 – Introduced Messing-gun which is routinely used for placement of amalgam at the
root end. 

Fig 13 : Messing Gun

 In 1943, American Association of Endodontists was formed. The year 1950 saw the development of
microsurgery and Digital Optical Microscopes were invented in 1960s.
 A more conservative attitude with regard to apical surgery developed in the late 1960s when Bhaskar
called attention to the fact that periapical cysts are present in more than 40% of cases, a much higher
incidence, than previously reported.
 During 1970s evolution of surgical endodontics is credited to the European professionals, who
detailed surgical flap designs and management of the resected root ends.
 In the latter half of the 20th century, reason and rationale were brought to surgical endodontics with
the extensive treatise on surgical endodontics by Jorgen Rud, Jens Andreasen and JE Moller-
Jensen. Their studies fostered the use of alternative root end filling materials that favored tissue
regeneration.
 Mahmoud Torabinejad, 1993 – Discovered mineral trioxide aggregate (MTA) was and brought
into use.
 CLASSIFICATION OF ENDODONTIC SURGERIES
A. According to Gutmann:

3. Corrective surgery
1. Fistulative surgery
a. Perforation repair
a. Incision and drainage (I&D) i. Mechanical (iatrogenic)
b. Cortical trephination ii. Resorptive
c. Decompression procedures b. Periodontal management
i. Root resection
ii. Tooth resection
2. Periradicular surgery c. Intentional replantation
a. Curettage
b. Root-end resection
c. Root-end preparation
d. Root-end filling
 CLASSIFICATION OF ENDODONTIC SURGERIES

Incision and drainage (I&D)

It involves as incision in dependent base of an intraoral

swelling, followed by probing into the swollen tissues with a
mosquito hemostat, curette or other instrument to release
exudate which may be entrapped in tissue compartments not
opened by incision.

Fig 14 : I&D
Cortical trephination

It involves an incision through mucoperiosteal

tissues, exposure of the surface of cortical bone,
penetration of the cortex with rotary instrument and
creating a pathway through cancellous bone to the
vicinity of the involved periradicular tissues.

Decompression procedures

It is a procedure design to reduce the size of the

lesion so that surgical intervention is unnecessary or
if necessary will be limited to the immediate
periradicular tissues of involved teeth.

Fig 15 : Cortical Trephination

Curettage

Excision or incision of pathological tissue Fig 16 : Curettage

related to the apical part of root, using a sharp
curette of suitable size.

Root-End Resection

Resection of the apical part of the root &

Fig 17 : Root-end
removal with the attached pathological tissue. Resection
 Fig 18 : Root-end
Preparation
Root-End Preparation & Root-End Filling

Root end preparation and root end filling is a

method of sealing the apical extent of the
root canal system through cavity preparation in
the resected root end and placement of a
restorative filling material. Fig 19 : Root-end
Filling
Perforation Repair

Fig 20 : Mechanical (Iatrogenic) Perforation

Fig 21 : Resorptive Perforation

 Periodontal Management

Fig 22 : Root Resection

Fig 23 : Tooth Resection

Intentional Replantation

FIG 24 : Intentional Replantation

FIG 25 : Intentional Replantation (Contd.)
B. According to Kim:
Classification according to various radiographic and
clinical presentations :

Class A : It represents the absence of peri-apical lesion

but unresolved symptoms after non-surgical approaches
have been exhausted. Clinical symptoms are only
reason for the surgery.

Class B : Represents the presence of a small peri-apical

lesion but no periodontal pockets.

Class C : Represents the presence of a largeperi-apical

lesion progressing coronally, but without periodontal
pockets.
Fig 26
Class D : Represents a clinical picture similar to
Class C, but with a periodontal pocket.

Class E : Classifies a peri-apical lesion with an

endodontic and periodontal communication, but no
root fracture.

Class F : Represents a tooth with an apical lesion

and complete denudement of the buccal plate.

Fig 27
 INDICATIONS
It is recognized that nonsurgical treatment is the
choice in most cases. However, the following
indications may have to be considered :
 Failure of nonsurgical endodontic retreatment.
 Failure of previous surgery
Fig 28 : Persistent periradicular pathology
 Anatomical problems
 Iatrogenic errors
 Horizontal apical root fracture
 Exploratory surgery and biopsy
 Periodontal considerations

Fig 29 : Perforation of the root due to Fig 30 : Persistent pain due to

improper post placement overfilling of the canals
 CONTRAINDICATIONS
The following factors play a major role in the surgical endodontics:
 Inadequate periodontal support and active uncontrollable periodontal disease
 Poor restorability with a post-endodontic restoration
 Lesions situated very close to important anatomical structures such as the inferior alveolar nerve,
lingual nerve, mental foramen, and maxillary sinus when there is a high risk of damage to these
structures
 Systemic complications of patients such as bleeding disorders, severe heart disease such as a patient
recuperating from a myocardial infarction, and immunocompromised patients
 Practitioner’s skill and experience with microsurgical treatment plays an important role
STEPS IN ENDODONTIC SURGERY
CASE DIAGNOSIS

PREOPERATIVE SURGICAL NOTES

ANESTHESIS / HEMOSTASIS

MANAGEMENT OF HARD AND SOFT TISSUE

SURGICAL ACCESS

PERIRADICULAR CURETTAGE
 ACCESS TO ROOT STRUCTURE

ROOT-END RESECTION

ROOT-END PREPARATION

ROOT-END FILLING

SOFT TISSUE REPOSITIONING & SUTURING

POST SURGICAL CARE

 ANESTHESIAS & HEMOSTASIS

BLOCK INFILTRATION
ANESTHESIS INJECTION

INCRESAED HEMOSTASIS,
PROLONGED DEEPER
BETTER VIEW OF SURGICAL
ANESTHESIS
FIELD

i. DESIRED LEVEL OF ANESTHESIA

ii. DESIRED LEVEL OF
VASOCINSTRICTION, DECREASING
THE BLOOD FLOW AT THE
OPERATION SITE
 MANAGEMENT OF SOFT & HARD TISSUE

 Firm incision is made with a sharp blade through the tissue.

 Usually one or more of four scalpel blades No. 11, No. 12, No. 15, and No. 15-C. but No. 15 is most
widely used
 Horizontal insicion is always made first, followed by vertical releasing incision.


Fig 31 : Different types of scalpel blades used for endodontic surgery

 Flap reflection is done by endodontic tissue retractors (Arens Tissue Retractor, Selden retractor,
University of Minnesota Retractor).

Fig 32 : Arens Tissue Retractor

Fig 33 : University Of Minnesota Retractor

Fig 34 : Seldon Retractor Fig 35 : Flap Retraction

 Apex is located by radiographs and by searching the bony defects.

 Bone is removed using round surgical burs with copious irrigation and surgical access is made.
 Burs used for gaining access to the bony crypt and for resection of the root apex are, No. 4 round bur;
No. 6 round bur; No. 8 round bur; No. 57 fissure bur; multi-purpose bur; Endo-Z bur.

Fig 36 : From left to right, No. 4 Round bur, No. 6 Round bur, No. 8 Round bur, No. 57 Fissure bur, Multi-Purpose
Bur, Endo-Z Bur
 PERIRADUCULAR CURETTAGE

 A curved bone curette is placed between the soft tissue mass & the lateral wall of the bony crypt with
the concave surface of curette facing the bone.
 Try to remove the inflamed tissue in one piece.

Fig 37 : Variety of spoon excavators

and curettes for removal of soft
tissue from the bony crypt.
FIG 38 :
A. Curettage of soft tissue lesion
allows for visualization of
mesiobuccal root apex. Tissue
removed should be submitted for
biopsy;
B. Root-end exposed and more visible
following curettage;
C. Soft tissue lesion overlying apex;
D. Root-end exposed following
curettage and osseous removal
 ROOT-END RESECTION

 Resection of the apical 3 mm of the root apex will eliminate 98% of the apical ramifications and 93%
of the lateral canals which could contain material that would contribute to the periradicular disease.
 Tapered fissure burs at high speed under sterile saline is most commonly used for root-end resection.
 No. 702 tapered fissure bur or a No. 6 or No. 8 round bur is used for resection.
 ER:YAG or CO2 Laser are also used for root-end resection.
 Angle of root resection should be 30º-45º from the long axis of root facing buccal or facial aspect of
root.

FIG 39 : No. 702 Tapered bur

FIG 39 : The "rule of threes": the root's last 3 mm is removed
by the apicoectomy and another 3 mm of the canal is FIG 40 : Groups made after root
instrumented and sealed by the retrocavity. So finally 6 mm resections at 0º, 30º and 45º bevels.
of the canal is enough to eliminate or block most frequent
communications at the apical third area between the main
canal and periodontium.
FIG 41 : (a). Incomplete root-end resection, (b). While it is seen on the mesio-distal
radiograph, (c). The incomplete root-end resection is not visible on a bucco-lingual
radiograph.
 ROOT-END PREPARATION

 3 mm deep preparation is made in the cut

surface of apex of root to accommodate the
root-end filling material.
 Traditionally small round burs or inverted
cone burs can be used for root-end
preparation but now a days ultrasonic
retrotips like KiS ultrasonic tips used in
conjunction with ultrasonic units.

FIG 42 : (a). Preparing With A Round Bur,

(b). Preparing With A Inverted Cone Bur.
As we can see there are chances of root-end perforation also
the preparation of a large sized cavity.
 FIG 43 : The active part of microtips should be
3mm long to maintain the rule of threes

FIG 44 : Difference between the microtips & low FIG 45 : KiS Ultrasonic Tips
speed microhead
FIG 46 : Schematic drawing showing ideal root end preparation when the ultrasonic tip is aligned along the long axis
of the root.
 ROOT-END FILLING

 The area is dried and isolated after irrigation with normal saline or distilled water. The root canal seen
through the cut end of the root is located.
 Root-end filling materials:
 Amalgam  GIC
 Zinc Oxide Eugenol Cements  Gutta-percha
 SuperEBA  Composites
 Intermediate restorative material (IRM)  Dyract
 MTA  Geristore
 Bioceramics
FIG 47 : Placement of root-end filling FIG 48 : Root-end preparation filled with
material into preparation. root-end filling material.
 SOFT TISSUE REPOSITIONING & SUTURING

 Flap has to be meticulously repositioned into the original position from where it was elevated.
Reapproximation is accomplished based on the flap design.
 The repositioned flap should always be kept moist with 2x2inch moist gauze until suturing has begun.

FIG 49 : Different needle tips and their sections left on soft tissues. The inverted triangle is the one most used. It increases
the needle's resistance, easily penetrates hard tissues with control, is the least traumatic, and prevents soft tissues from
tearing out.
 The different types of suture materials are;

NON-ABSORBABLE SUTURES ABSORBABLE

SUTURES
 Silk  Polyglactin
 Nylon monofilament  Monocryl
 Polyester
 Polypropylene
 GoreTeX

 Different types of knots;

 Slip Knot
 Square Knot / Granny Knot
 Surgeon Knot
 FIG 50 : Slip Knot FIG 51 : Square Knot / Granny FIG 52 : Surgeon’s Knot
Knot

 The different types of suture techniques are;

 Single Interrupted Suture
 Interrupted Loop (Interdental) Suture
 Vertical Mattress Suture
 Single Sling Suture
FIG 53 : Single interrupted sutures can be used for FIG 54 : Vertical mattress suture avoids penetration of
both the horizontal tissues in the incisional wound and supports the
incision and the vertical incision. interdental papilla in a coronal direction.
FIG 55 : Sling suturing technique FIG 56 : The "2 mm suture rule": leaving 2 mm
of tissue between the needle entering and exiting
and the incision line, and between two
consecutives stitches. This prevents tissues from
tearing out.
 POST OPERATIVE CARE

 No difficult activity or work for the rest of day.

 No alcohol or any tobacco for next 3 days.
 Good nutritious diet.
 Drink lot of liquids for first few days after surgery.
 Do not lift up lip or pull back cheek to look at where surgery was done. It may pull the stitches loose
and cause bleeding.
 A little bleeding from the surgical site is normal and it can last for few hours. Little swelling or
bruising of face is normal and may last for few days.
 Intermittent application of ice bags on face where surgery was done for 6–8 hours
 Take prescribed medicines regularly.
 Remove suture and make follow-up appointment.
 ENDODONTIC MICROSURGERY
 Dr. Harvey Apothkar coined the term microdentistry in 1980. Microsurgery is applicable to
endodontic surgeries today.
 Microsurgery is defined as a surgical procedure on exceptionally small and complex anatomical
structures with a DOM.
 The microscope enables the surgeon to assess pathologic causes more precisely and remove the
pathologic lesion with far greater precision, thus minimizing tissue damage during surgery.

Endodontic Microsurgical Traid

Magnification Illumination Instruments

 MAGNIFICATION

 The advent of magnification aids has greatly revolutionized dentistry and especially endodontics.
 Either using a dental loupe or preferably employing a dental operating microscope (DOM) can achieve
enhanced visualization in clinical dentistry.
 The introduction of DOMs has revolutionized a new era in endodontics.
 The present DOMs can be configurated to magnification levels up to x40 and beyond.
 Different range of magnification:
 Low-range magnification (x2.5 to x8)
 Midrange magnification (x8 to x14)
 High-range magnification (x14 to x30)
FIG 57 : Comparison of magnification ranges: Eye VS Loupes VS Microscopes
 Low-range Magnification is used for :
 Orientation
 Inspection of surgical site
 Initial osteotomy
 Ultrasonic tip alignment
 Suturing (x6.0)
 Suture removal
 Midrande Magnification is used for :
 Access  Root tip identification
 Orifice identification  Root-end resection
 Fracture identification  Root surface inspection
 Obturation  Root-end preparation
 Hemostasis  Root-end filling
 Tissue removal  Root amputation
 High-range Magnification is used for :
 Orifice identification
 Fracture identification
 Calcified canal location
 Identification of fine anatomical details
 Documentation
 Root surface inspection
 Root end preparation inspection
 Root end filling inspection
 Identification of fine anatomical details
 Documentation
FIG 58 : Coronal pulp space and orifice visualization at various levels of magnification.
From left to right 2.5x, 4x, 6x, 8x & 12x
 Before getting into magnification we need to understand some terms:
i. Working Distance : The distance measured from the dentist’s eye to the treatment field being
viewed.
ii. Depth of Field : The amount of distance between the nearest and furthest objects that appear in
acceptably sharp focus.
iii. Convergence Angle : The aligning of two oculars to be sure they are pointing at the identical
distance and angle to the object or treatment field.
iv. Field of View : The area that is visible through optical magnification.
v. Viewing Angle : The angular position of the optics allowing for a comfortable viewing position for
the operator.
FIG 59 : Convergence Angle FIG 60 : Working Distance
 DENTAL LOUPES

 These are the most commonly used magnification systems in dentistry.

 All loupes use convergent lenses to form a magnified image.
 Classification of dental loupes :
I. Based on kind of lense being employed –
1. Diopter / Flat-plane /Single Lense Loupes
 Most economical but can lead to compromised posture, musculoskeletal stess and fatigue.
2. Surgical telescopes with a Galilean system
 Most recommended. Compact & light weight
3. Surgical telescopes with a Keplerian system
 Employ refractive prisms. Heavier.
 FIG 62 : Single Lense Loupes

FIG 63 : Surgical
telescopes with a Galilean
system

FIG 64 : Surgical
telescopes with a
Keplerian system
FIG 61 : Ocular angles and viewing
directions of loupes
II. Loupes can also be classified based on how the lens are mounted to the frame:
1. Flip-up loupes
2. Through the lens (TTL) loupes
 DENTAL OPERATING MICROSCOPES (DOM)

 Innovation of DOMs was one of the most important innovations in past 3 decades.
 On January 1998, the ADA Accreditation Standards for Advanced Specialty Education Programs in
Endodontics were revised; formal microscope training must be included in surgical and nonsurgical
endodontic treatment.

FIG 65 : Dental Operating

Microscope
FIG 66 : Ocular angles and viewing
directions of microscope
 History of Microscope :
 Otologist – Introduced Operating Microscope.
 Dr Carl Nylen, 1921 – Monocular Microscope.
 Carl Zeiss, 1953 – Binocular Operating Microscope.
 1960 – 1st Surgical Microscope.
 Apothekar & Jako 1978, – DOMs.
 1980 – DOM (Dentiscope).
 Dr Gary Carr, 1991 – Introduction of ergonomic
DOM with Galilean optics
 1993 – Symposium on Microscopic Endodontic
Surgery.
 1995 – DOM by Endodontics
 1997 – Microscopy Training.

FIG 67 : The original Dentiscope

FIG 68 : Key microscope features
 Parts of Microscope :
a. Eyepiece Lens
b. Binoculars
c. Magnification Changer
d. Focusing Knob
e. Objective Lens
f. Body Support Of Microscope
g. Beam Splitter
h. External Monitor or Co-observation Tube
i. Picture and Video Adapters
j. Digital Picture Camera
k. Video Camera
a. Eyepiece Lens :
 The operator views the field through the eyepiece lens. Both the eyepiece and the objective lens
have convex lenses.
 Eyepieces have adjustable diopter setting to adjust for accommodation (ability to focus the lens of
the eyes).
 There are three types of eyepiece, depending on quality and optical aberration correction properties:
 Huygens (H), the most simple and cheap.
 Wide-field (WF), with good vision in all the field , edges included
 Plossl (PL), the most sophisticated and high quality with good correction of all optical
aberrations.
 They are available with 6.3, 10, 12.5, 16 and 20 magnification powers. They have an adjustable
diopter setting and rubber cups. Most commonly used are 10x & 12.5x.
 FIG 69 : Oculars differ ln magnification, but basically they all have a diopter scale and rubber cups. Users
wearing spectacles can adjust them or introduce their own eye data into the diopter scale, so they work at the
microscope without glasses. A wide
ocular is advised in order to have a greater field view.
b. Binoculars :
 It projects an intermediate image into the focal plane of the eyepieces.
 They are set at the interpupillar distance.
 Binoculars come with different focal lengths; the longer the focal length, the greater the magnification.
 Inclinable binoculars are adjustable for positions up to and sometimes beyond 180 degrees.
 Other ergonomie tools are the C-code beam splitter and the Carr extender. These bring the binoculars
away from the microscope and closer to the surgeon.
 Other lateral adjustments may be made with the mechanical optical rotating assembly (MORA) on the
Pico Zeiss microscope.
FIG 70 : Binoculars hold the eyepieces.
FIG 71 : 180-degree inclinable binoculars are a critical tool for working ergonomically.
 FIG 72 : (a) The Carr extender, for
(b) the Global operating microscope

FIG 73 : Comparison of use of

(a) the flat beam splitter, with a more
forward operator's back position , and (b) a
45-degree angled one that allows a
straighter back.
 FIG 74 : This mechanical optical
rotating assembly allows a 25-degree
tilting of the microscope body with
respect to the binoculars, to
accommodate the surgeon in the area of
working

FIG 75 : Use of the assembly

c. Magnification Changer :
 Located in the microscope body, the changer holds the lenses that magnify the image in three or five
steps manually or progressively if motorized.

FIG 76 : Knobs for manual fine

focus control (yellow arrow) and FIG 77 : (a) Inner ring or (b) handle controls for both fine motorized
manual magnification change (red focus and magnification
arrow)
 Total magnification of a microscope is determined by :
Mt = (ft/fo)MeMc

Mt = Total Magnification
ft = Focal Length Of Binoculars
fo = Focal Length Of Ojective Lens
Me = Eyepiece Magnificarion
Mc = Magnification Changer

d. Focusing Knob :
 The manual focusing knob changes the distance between the microscope lens and the surgical field.
 Motorized focusing is controlled by the inner ring and moves the objective lens closer to or away from
the surgical field.
e. Objective Lens :
 The focal length of the objective lens determines the distance between the lens and the surgical field.
 The closer the objective lens to the surgical field, the higher the final magnification at each step, and
the smaller the diameter of the surgical field will be but also, the smaller the space for passing
instruments, and the greater likelihood of the objective lens being splashed.
 The longer the focus of the objective lens, the greater the working distance will be.
 Taller surgeons will need a longer objective lens to have their torso further away from the operating
field.
 A variety of objective lenses are available with focal lengths ranging from 100 mm to 400 mm.
 Typical working distances are: 8 inches (20 cm) for a 200-mm lens; 10 inches (25 cm) for a 250-mm
lens; and 14 inches (35 cm) for a 300-mm lens.
 Lenses from 200 mm to 250 mm are recommended for endodontic microsurgery because they provide
a comfortable working distance and enough room for passing instruments.
 State-of-the-art optics today allow a wide focal length range with a fixed objective lens.

FIG 78 : Different objective lenses provide different working lengths.

f. Body Support Of
Microscope :
 Microscope support is
provided by two systems:
springs or electromagnetic
clutches.
 A free-floating magnetic
clutch system offers the
easiest way to move the
microscope and more
important, a totally stable
position regardless of the
FIG 79 : As soon as one of the black buttons is activated, the
weight of the microscope. microscope body is totally free-floating. It can then easily be moved
by one hand to any desired position. When the button is released.
electromagnetic clutches are activated and the microscope rendered
absolutely immobile.
g. Beam Splitter :
 A straight beam splitter or a C-code splitter can be inserted into the pathway of the light, as it returns to
the operator's eye, between the binoculars and the magnification changer.
 Its function is to supply light to accessories :
 Real time images can be shared with the assistant through an external LCD monitor or a co-
observation tube.
 Pictures can be taken with a digital camera.
 Video can be taken with a one- or three-chip digital video camera.
 FIG 80 : (a) and (b) This straight
beam splitter between the microscope
body and binoculars sends the surgical
field image to documentation accessories.

FIG 81 : (a) and (b) This 45-degree

inclined C- splitter between the
microscope body and binoculars sends the
surgical field image to documentation
accessories
h. External Monitor or Co-observation Tube :
 A straight beam splitter or a C-code splitter can be inserted into the pathway of the light, as it returns to
the operator's eye, between the binoculars and the magnification changer.
 The image signal can be shared to an external monitor situated at the surgeon's back, in front of the
assistant, so the assistant can view the surgical field on the monitor without moving his or her head,
and can help the surgeon by passing instruments ("four-handed dentistry").
 The co-observation tube brings the assistant right into the surgical field with higher motivation to help
the surgeon in retraction and aspiration of the surgical field; another assistant would be required to
anticipate the surgeon's next step in the procedure by passing instruments ("six-handed dentistry").
 FIG 82 : A co-observation tube allows an assistant to see
what the surgeon is seeing.

i. Picture and Video Adapters :

 Picture adapters are made by the microscope companies or are created by clinicians.
 A video adapter has a different focal length from the picture adapter.
 Today, picture and video adapters allow the use of the newest consumer high-resolution cameras.
 FIG 83 : (a) and (b) The
function of a picture adapter is
to attach a digital camera to
the beam splitter and provide
the same necessary focal
length, so that the camera can
record an image with the same
magnification and field of
view as that seen by the
surgeon.
(c) Carr II (Dr Carr) and (d)
Xmount (Dr Herbranson)
adapters allow horizontal or
vertical attachment of a
compact or SLR picture
camera to the operating
microscope.
j. Digital Picture Camera :
 Photography is all about Iight reflected back from the object into the camera. That is why it is so
important to consider the power of the light source, the amount of light reflected by the mirror, the light
transmission factor of the microscope and the digital picture camera lenses.
 ln the past, 35 mm film cameras and halogen Iight were used and taking a good picture was a frustating
and discouraging experience.
 Today, digital picture cameras are more light-sensitive and good pictures can be taken at low
magnification with halogen Iight with no problem.
 But,
More Magnification =
k. Video Camera :
 It is more light-sensitive than a digital picture camera and does not require an additional strobe light.
 Also, a video camera has more depth of field than a digital picture camera, so documentation is much
easier.
 The resolution of the video camera should be matched to the resolution of the video recorder and the
monitor.
FIG 84 : (a) and (b) New adapters allow the use of high-resolution consumer picture and video cameras, making
professional documentation potentially cheaper.
Advantages Of DOMs
 Increased diagnostic power.
 Broader therapy treatment spectrum.
 Reduced trauma.
 Marketing benefits to the surgeon's professional practice.
Disdvantages Of DOMs
 Learning curve.
 Workplace arrangement and seated posture.
 Skills acquisition.
 Assistants' learning curve.
 Longer sessions.
 Expensive armamentarium.
Some important points related to DOMs :

 Golden Rules For Buying Microscope

 Collect more information before buying.
 Attend hands on training programs along with the assistant and learn from experts.
 Should be easy to upgrade microscope in the future.
 In magnification we should always keep in mind that less is more, i.e., magnification with 3-20x is
more practical to use than 5-30x because in 20x everyone can work comfortably for longer period
and also easily record the case due to good depth of field.
 Installation of microscope – Wall mounted, Ceiling mounted & Floor mounted / free to move.
With wall & ceiling mounted the DOM can be used in a single chair but with floor mounted it
can be transferred to another chair.
But it is also recommended that the microscope should be stable it’s always better to move the
patient rather than moving the microscope.
FIG 85 : A ceiling mounted FIG 86 : A wall mounted FIG 87 : A floor mounted
microscope microscope microscope
 ILLUMINATION

 One of the advantages of using a microscope is its ability to provide coaxial illumination.
 Coaxial illumination means that the light-source path and the line-of-sight path are similar. This
enables a microscope to illuminate the object of interest clearly without any shadows.
 Powerful LEDs are used as the light source in conventional microscopes.
 Halogen lighting was the first dental microscope light source introduced.
 Xenon and the more recent LED light sources were developed to deploy better illumination to the
operating field.
 Recent developments include depolarization and daylight UV filters, as well as fluorescence for caries
detection.
 FIG 89 : Light :
FIG 88 : Coaxial Illumination
Colors & Temperature
 MICROSURGICAL INSTRUMENTS

 Instruments can be categorized accordingly :

a. Examination & Inspection Instruments
b. Incision, elevation, and curettage instruments
c. Retraction instruments
d. Osteotomy and apical root resection instruments
e. Instruments for preparing root end
f. Irrigational instruments
g. Hemostasis instruments and materials
h. Suturing materials
i. Tweezers, forceps, scissors, and needle holders
j. Needles
a. Examination & Inspection Instruments

FIG 91 : Periodontal Probe

FIG 90 : Micromirrors FIG 92 : DG-16

 b. Incision, elevation, and curettage
instruments

 The miniblade are small enough to

manage the interproximal papilla
and large enough to make a vertical
releasing incision in one stroke.

FIG 93 : Miniblades with handle

 Molt curette - design of the working
end is such that the working tip is
sharp, which facilitates easy
elevation of a full-thickness flap
along with the periosteum.
FIG 94 : Molt curette No. 2/4
 Used to spoon out the lesion.
FIG 95 : Jacquette curettes

FIG 96 : Periosteal elevator

 Retraction instruments
 KP-1, -2, and -3 retractors
 Carr #1, 45º retractor serrated
edge for posterior applications.
 Carr #2, 90º retractor serrated
FIG 97 : Retractors
edge for anterior applications.
 Osteotomy and apical root resection
instruments
 Impact Air 45º handpiece
 Lindemann burs
 Micromirrors and microexplorers

FIG 99 : Impact Air 45º

 Instruments for preparing root end

 Microsurgical ultrasonic
instruments
 MTA root-end filling material
FIG 100 : Lindemann Bur
 Irrigational instruments
 Stropko irrigator
 Microsuction

 Hemostasis instruments and

materials
FIG 101 : Stropko Irrigator

 Suturing materials

 Tweezers, forceps, scissors, and

needle holders

 Needles
FIG 102 : Microsuction
 Difference
Between
Traditional
And
Microsurgical
Endodontic
Surgery
 SOFT TISSUE MANAGEMENT
 The importance of the soft tissue management is crucial if a correct esthetic and functional result is to
be achieved.
 Two aspects are of equal importance : the design and management of the flap and the suturing
technique.
 The flap design is extremely important because it must allow sufficient blood supply to the mobilized
and non-mobilized soft tissues.
 Also factors, incidents and modifications of the ongoing surgery must be taken into consideration
before the first incision is made.
 Tension on the flap introduced during surgery leads to extra postoperative pain and inflammation, and
this tension is directly related to the flap design.
 Modifications to the flap after the incisions have been made can jeopardize the final result.
 FLAP DESIGN & PREPARATION

 Based on several studies, there are several flap designs suggested by endodontists.
 However, all the flap designs have both advantages and disadvantages and no single flap design is
suggested in all the surgical cases.
 To obtain a good surgical access, one must select an appropriate flap design depending on several
factors.
 Each endosurgical case may require a specific flap design based on the size, site, and proximity to
anatomical structures.
 RULES FOR FLAP DESIGN
 Tissue incisions, elevations, and retractions are performed meticulously in a manner that facilitates
healing by primary intention.
 A complete and sharp incision deep into the bone at one stroke is mandatory.
 Incision is made through the gingiva and the periosteum to the cortical bone using firm pressure and
one single stroke.
 Multiple incision lines will result in improper suturing and delayed healing and scar formation as well.
 Vertical releasing incisions are never placed on the radicular bone but on the interdental bone.
 Releasing incisions between bone eminences should be over concave bone surfaces and never cross
convex bone eminences.
 "The shorter the vertical incisions, the larger the horizontal one; the longer the vertical incisions, the
shorter the horizontal one."
 Classical time-tested BP handle grips and supports are used while placing incisions.
 There should be minimum trauma to the remaining tissues.
 Care should be taken of the incised flap under moist and retracted conditions with tissue retractor.
 Releasing incisions may be required for efficient suturing.
 The interdental papilla has to be protected and preserved in both anterior esthetic zones and posterior
regions.
 Atraumatic tissue handling is mandatory to obtain a scar-free healing. This in turn makes way for a
more predictable healing.
FIG 103 : Incisions must never cross the bone defect boundaries. Normally, the bone defect may be larger than it
appears on the radiograph, so incisions must be made further away.
FIG 104 : If the bone lesion is at the second premolar, a mesial releasing incision should be made on the first premolar
(B) or canine (C), instead of between premolars (A).
FIG 105 : Keeping releasing incisions in between bone eminences, where the tissues are thicker, makes flap raising an
easier and safer task than crossing bone eminences where tissues are thinner and tearing and necrosis more likely.
FIG 106 : ln the top picture the incision crosses over the canine bone eminence. Below, the incision is between lateral
and canine eminences.
FIG 107 : The incision must never finish on thin buccal tissue (red line), nor on papilla, because compromising the fine
vascularization can cause necrosis and a poor esthetic result. The incision can be tilted a little (green line), without
crossing the next tooth bone eminence, in order to open the angle and keep the incision in attached gingiva.
 FIG 108 : Entry into the mucolabial fold must be avoided, because here there
are only elastic fibers, a lot of vascularization, difficult suturing and removal, and pain and edema in the postoperative
period normally occurring due to lip movements.
 a b

FIG 109 : (a) and (b) Vertical releasing incisions should follow the vascularization direction in order to prevent areas of
ischemia from occurring.
FIG 110 : A trapezoidal flap with possible area of necrosis (c) & (d).
FIG 111 : Intact periosteum must be raised together with the flap, normally in a coronal to apical direction, with a sharp
elevator at an oblique angle with the longitudinal direction of the root and with constant contact with the bone by the
concave surface of the instrument.
FIG 112 : If the retractor presses on the flap, vascularization is compromised with possible ischemia of the flap, leading
to more postoperative pain and flap inflammation. The tension on the flap produced by the retractor can be reduced by
angulation of the retractor, or by making the flap larger.
FIG 113 : Suturing's rule of thumb is: epithelium - connective tissue (released tissue) - connective tissue - epithelium
(unreleased tissue).
 ARMAMENTARIUM

 Surgical blades 15C, BB#369  Scalpel handle  Tissue forceps

FIG 114 : Surgical Blade 15C

FIG 115 : Surgical Blade BB#369

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

FIG 116 : Microsurgical Tissue Forcep

 CLASSIFICATION OF SURGICAL FLAPS

According to Gutmann & Harrison (1984) :

I. Full mucoperiosteal flaps
1. Triangular (single vertical releasing incision)
2. Rectangular (double vertical releasing incision)
3. Trapezoidal (broad-based rectangular)
4. Horizontal (envelope)
5. Papilla-based flap

II. Limited mucoperiosteal flaps

1. Submarginal curved (semilunar)
2. Submarginal scalloped rectangular (Luebke-Ochsenbein)
FIG 117 : (a) A full mucoperiosteal flap includes the (i) mucosa, (ii) connective tissue, and (iii) periosteum.
(b) To elevate the mucoperiosteal flap, the incision must be made to the bone.
1. Triangular Flap :
 Introduced by Fischer in 1940.
 AKA Sulcular Triangular Flap.
 It consists of one horizontal sulcular incision & only
one vertical releasing incision. Both incision extends
atleast one or two teeth away from the bony lesion.
 Additional access can be provided with a small distal
relaxing incision.
 Indications :
 Tooth with short roots
 Premolars FIG 118 : Triangular Flap
 Molars especially for palatal roots
 When bone graft is necessary
 Advantages :
 Incisions never cross the bone lesion.
 Access to lateroradicular lesions.
 Easy reposition.
 Preservation of flap vascularization.

 Disadvantages :
 Little difficult elevation initiation.
 Can produce gingiva marginal level modifications around prosthetic crowns, or soft tissue crevice or
periodontal pockets.
 Incisions should be long enough to facilitate access to long root teeth’s apices and decrease flap
tension.
 Suture more difficult between teeth.
 Hygiene difficult.
 FIG 119 : Full mucoperiosteal triangular flap
with one vertical incision and a horizontal
intrasulcular incision. A distal vertical relaxing
incision (dotted line). FIG 120 : A triangular flap made with one vertical incision. This is a
very practical flap for short roots, premolars and molars, preventing
damage to important landmarks and allowing access lor a bone graft
donor area.
2. Rectangular Flap :
 AKA Sulcular Rectangular Flap.
 It consists of one horizontal sulcular and two vertical
releasing incision.
 Incisions are made one or two teeth away from the
lesion.
 Indications :
 Anterior teeth
 Limited attached gingiva
 Long roots
 Big lesion FIG 121 : Rectangular Flap

 Exploratory surgery
 1/3 cervical lesion
 Surgery of multiple teeth required.
 Advantages :
 Access to surgery field is easy.
 No tension on the flap.
 Access to lateroradicular lesions.
 For long roots.
 Easy flap repositioning.

 Disadvantages :
 More difficult elevation.
 Diminished flap vascularization.
 Can produce modification of the level of the marginal gingiva.
 Suturing more difficult between teeth.
 Hygiene difficult.
FIG 122 : Full mucoperiosteal rectangular flap with two vertical releasing incisions and a horizontal intrasulcular
incision.
3. Trapezoidal Flap :
 AKA Apron Flap.
 Neumann and Elkan in 1940 introduced trapezoidal flap.
 Similar to the rectangular flap with the exception that the two vertical releasing incisions intersect the
horizontal, intrasulcular incision at an obtuse angle.
 The angled vertical releasing incisions are designed to create a broad-based flap with the vestibular
portion being wider than the sulcular portion.
 The desirability of this flap design is predicated on the assumption that this will provide a better blood
supply to the flapped tissues but resulted in more bleeding, a disruption of the vascular supply to the
non-flapped tissues, and shrinkage of the flapped tissues.
 Contraindicated in periradicular surgery.
FIG 123 : Trapezoidal Flap
4. Horizontal Flap :
 AKA Envelop Flap, Gingival Flap.
 It is a flap consisting of only horizontal intrasulcular incision & no vertical incision.
 Indications :
 Cervical defects like root perforations, resorption, caries, etc
 Hemisections
 Root amputations.
 Advantages :
 Minimal disruption of vascular supply to flapped tissue, ease of wound closure and good post
surgical stabilization.
 Disadvantages :
 Limited surgical access.
FIG 124 : Horizontal Flap
5. Papilla-Based Flap :
 Velvart introduced papilla-based flaps.
 It was designed to prevent recession of the papilla
following endodontic surgery as it essentially excludes
the papillae.
 The technique involves two different incisions at the
papillary base: a shallow first incision at the base
followed by a second incision directed toward the
crestal bone.
 Once the papillae are incised, a full thickness
mucoperiosteal flap is elevated.
 Although this flap design is more challenging to
master, if properly executed, it can produce excellent FIG 125 : Papilla-Based Flap
results.
6. Submarginal Curved Flap :
 AKA Semilunar Flap, Partsch incision, Bogenschitt incision.
 The incision begins in the alveolar mucosa extending into the attached gingiva and then curves back
into the alveolar mucosa.
 Once was suitable only for incision and drainage.
 It has limited access to the surgical area and has poor visibility.
 Once the semilunar flap is elevated, it is extremely difficult to modify once the surgery has started.
 There are more chances of scar formation as well as puckering in if there is no cortical bone support
for the flap.
 Not recommended now a days for periradicular surgery.
FIG 126 : The semilunar flap does not satisfy any of the FIG 127 : Scar (arrow) in the gingival tissues resulting
golden rules and is now used only for incision and from the use of a semilunar flap for periapical surgery.
drainage.
6. Submarginal Scalloped Rectangular Flap :
 AKA Luebke-Ochsenbein Flap.
 Neumann in 1926 published text which were similar to modern day Luebke-Ochsenbein Flap.
 Similar to the 'trapezoidal' flap, but a scalloped horizontal incision is made in the attached gingival
strip in order not to modify the gingival margin profile.
 A minimum 2-3 mm strip width is necessary to prevent necrosis and recession of unreflected tissue.

 Indications :
 Anterior teeth
 Prosthetic crown present
 Long roots
 3-mm strip of attached gingiva necessary
 Advantages :
 Easy incision and easy flap elevation.
 Good access and visualization.
 Prevention of non-pathological dehiscences.
 Easy repositioning.
 Hygiene easy.

 Disadvantages :
 Incision can cross the bone lesion.
 Flap corners can become necrotized.
 Horizontal incision can cross frenums etc. or if too close to the gingival sulcus can produce
crevices.
 Suturing difficult
 Tension can produce wound dehiscence and scar formation.
FIG 129 : Luebke-Ochsenbein Flap
 FIG 130 : Luebke-Ochsenbein Flap design.
Incisions extend from a point 1–2 mm short of entering the mucobuccal fold to a point on the attached gingiva 3–5 mm
above or below the marginal gingiva and sulcus depth.
 INCISION

 During surgery, soft tissue management is commonly overlooked because, once the flap is retracted,
attention is usually concentrated on the defect.
 To achieve neat flap edges, incisions should be made with a firm and continuous movement of the
blade that maintains permanent contact with the bone surface. Use a lower magnification of the
operating microscope (4x).
 "Pencil" holding is the most used hand position.
 The normal contact angle of the blade to the soft tissues and bone is 90 degrees.
FIG 131 : Holding the blade's handle as FIG 132 : Ninety degrees is the standard
with a pencil. cutting angle.
 Two types of incision :

A. Horizontal Incision : It begins with the intrasulcular incision that extends from the gingival sulcus,
through the fibers of the dentogingival union up to the crestal bone. The remaining tissue in the
interdental space facilitates the flap papilla reattachment and prevents loss of soft tissue attachment
level.

B. VerticalIncision : It starts perpendicular to the line angle of the tooth up to the middle of the base of
the papilla, and then turns to follow vertically and sever perpendicularly fiber lines of the attached
mucosa and periosteum between bone eminences.
FIG 133 : (a) to
(c) This sulcular
incision will
sever
dentogingival
fibers up to the
crestal bone.

FIG 134 :
Horizontal
sulcular incision
with a No. 11
Bard Parker
scapel blade
 FIG 135 : Model of a vertical incision. FIG 136 : Vertical incision with a No. 15
It starts perpendicular to the angular line Bard Parker scapel blade.
and continues between bone eminences.
 ELEVATION

 The purpose is to raise the already cut flap to allow visibility of the bone.
 The flap should be elevated in such a way that, on re-approximation, it will rest passively in the
desired position.
 A sharp, small, straight or curved elevator is placed at the junction of the horizontal and vertical
incisions, with its concave surface against the bone.
 These contours are not flat and smooth; they have irregularities that contribute to tearing or perforating
of the tissues, so a change of elevation direction is necessary.
 The periosteum should be raised together with the flap in order to minimize bleeding during surgery,
facilitate suturing, diminish pain and inflammation and speed up healing.
 Peeling the periosteum over smooth bone surfaces is easy with an instrument.
 If resistance to raising is excessive, one of the
following may apply:
 the incision was not clean up to bone.
 the elevator blade is not sharp.
 the support angle is very small.
 the size and shape of elevator are incorrect.
 perforation of the bone plate has welded the
granulation tissues of the bone lesion and the
submucosa of the flap.

FIG 137 : Elevation is started by inserting the elevator edge

at the junction of the vertical and horizontal incisions.
Vertical force is applied with a slow, firm and controlled
peeling motion, following closely the cortical bone
contours, in order to release the flap to a level superior or
inferior to the lesion.
FIG 138 : If the bone crest is thick and irregular,
coronal-apical flap elevation can be difficult.
FIG 139 : When resistance to raising the flap is experienced. the normal coronal to apical direction (a) is changed to a
lateral apical to coronal direction (b) until the flap end is raised; then the coronal to apical direction is resumed (c).
FIG 140 : (a) The blade has not reached the bone surface. (b) Even with an incision up to the bone crest, but with a
blunt elevator. tearing of the flap's edges can occur.
FIG 141 : Elevation is a difficult task with a small support angle. or without a properly sized and shaped instrument.
 RETRACTION

 Retraction is done to maintain the flap allowing maximum access and visibility without causing
damage to the flap or neighbouring tissues.
 A correct retraction technique improves ergonomics, and reduces the time of the surgery and the
postoperative pain and inflammation.
 Retractors are one of the most important instruments for endodontic microsurgery, and they must have
certain characteristics:
 They must be wide enough to hold all the flap (15 mm).
 They must be thin enough (0.5 mm) to improve access.
 They should have a serrated working end to prevent sliding.
 They should have a matt surface, so light is not reflected.
 Working ends must adapt, as far as possible, to the cortical bone plate of the specific surgical area.
 Sliding and subsequent repositioning causes tearing and traumatization of the retracted tissue, disturbs
the surgeon's concentration, and makes it necessary to readjust the microscope, significantly
lengthening surgery time. Also, Iips and cheeks can be damaged by retractor sliding. Pinching can be
produced by leaning the retractor on soft tissue.
 Normal dehydration and flap shrinkage occur, but excessive tension over the flap can causes ischemia
during the time of the retraction, so flap rehydration with saline is advised.

FIG 142 : Classic Retractors FIG 143 : Rubinstein retractor set for all FIG 143 : Minnesota and
surgical areas. Prichard retractor
 SUTURING

 Sutures maintain the position of the flap reattachment during the initial phase of the first-intention
healing process.
 A suture should just compensate for the tension of the flap. It should be atraumatic, nonallergenic, and
easy to use.
 Armamentarium :
 Sutures
 Tissue forceps
 Needle holder
 Scissors
 Instrument case
 Types Of Healing :
 Needles :
 The ideal length, size, design of the needle and suture are dictated by the flap thickness, incision
location, suture technique employed , etc.
 No single needle shape and radius is ideal for every situation.
 Needles must be :
 made in high-quality stainless steel
 as thin as possible without sacrificing strength
 stable when grabbed by the needle holder
 able to slide the suture material when it passes through the tissue causing minimal trauma
 sharp enough to penetrate the tissue with low resistance
 rigid enough to resist twisting, and at the same time flexible enough to bend before breaking
 sterile and corrosion-proof
 of a size compatible with the suture caliber, allowing both to work as an entity.
 A needle length of 16 to 20 mm is necessary when suturing a buccal flap with sulcular incision
(rectangular, triangular flaps) to the unreleased palatal side.
 A length of 8 mm or shorter is best when suturing paramarginal incisions (Luebke-Ochsenbein) or
Papillary-based flaps.
 The inverted triangular cut is the most used cross-section at the tip and body.
FIG 144 : (a) and (b) The sharper the needle's tip, the less force is required for tissue penetration.
 FIG 145 : Different needle tips and their sections left on soft tissues.
The inverted triangle is the one most used. It increases the needle's resistance, easily penetrates hard tissues with control, is
the least traumatic, and prevents soft tissues from tearing out.
 Sutures :
 Because sutures are a foreign material in the body and impede the healing process, the minimum
number of stitches and the thinnest suture that provides adequate flap reattachment should be used.
 Sutures should be removed at the earliest biologically acceptable time (minimum 48 h, maximum 96
h).
 The 5-0, 6-0 and 7-0 monofilament suture has replaced the 4-0 silk suture as the standard choice.
 Generally, 5-0 is used for suturing flaps with sulcular incisions and free gingiva, and 6-0 and 7-0 for
suturing flaps with paramarginal incisions on attached gingiva.
 Microsurgery tends to increase the number of stitches while reducing the size of the suture.
 Furthermore, the small size of the suture prevents the surgeon from exerting an over-tension on flap
tissue.
 Multifilament sutures have easy handling and knot security, but also suffer hydration and
contamination .
 Monofilament sutures have worse handling and worse knotting, but suffer less contamination .
 Absorbable sutures produce inflammation while being absorbed.
 Non-absorbable sutures are more biologically inert.
 Surgical wounds gain strength rapidly in the first few days owing to non-collagenous proteins, so
non-absorbable sutures are the best choice for endodontic microsurgery.
 However, a 5-0 absorbable suture can be used in the particular areas of vertical releasing incisions.
FIG 146 : Silk 4-0 has been replaced by
monofilament 6-0 or 7-0.
This picture shows a 20 mm needle
compared to a 9 mm needle.
 Classification :
Classification I

Absorbable Suture Material Non-Absorbable Suture Materials

Plain Catgut Silk

Chromatic Catgut Polypropylene (Prolene)
Vicryl (Polyglactic acid) Polyethylene (Ethylene)
Cotton
Dexon (Polyglycolic acid)
Linen
Maxon (Polyglyconate))
Steel
PDS (Poly Dioxanone Suture Material)
Polyester
Monocryl (Polyglecaprone)
Polyamide
Biosyn (Glycomer) Nylon
 Classification II

Natural Synthetic

Vicryl
Catgut
Silk Dexon
Cotton Polydioxanone Suture
Linen Maxon
Polypropylene
Polyethylene
Polyester polyamide
 Classification III

Braided Twisted

Cotton
Polyster
Polyamide Linen
Vicryl
Dexon
Silk
 Classification IV

Monofilament Multifilament

Polyester
Polypropylene
Polyethylene Polyamide
PDS Vicryl
Catgut Dexon
Steel Silk
Cotton

Classification V

Coated Uncoated
 Silk :
 Silk is a multifilament braided suture with a high standard moisture regain : the "wick effect".
This results in plaque formation within a few hours after insertion into the tissues.
 Silk is strong, available in a variety of lengths, easy to use and knot, easily identified even
when buried in swollen tissues, cost effective, rarely allergenic, and available in sizes from 0-0
to 6-0.
 Although it is still the most widely used suture material overall, its sole advantage is ease of
use and it is not recommended for endodontic microsurgery.

FIG 147 : (a) SEM picture

of silk cut with scissors.
(b) A silk suture covered
by plaque four days after
surgery.
 Nylon monofilament (polyamide polymer): Ethilon, Supramid :
 These non-absorbable suture materials are inert, strong, with a smooth non-porous surface that
makes them impenetrable to bacteria.
 Some monofilaments, up to 6-0, are difficult to tie and have a tendency to cut through tissue
when pulled during placement or mouth movement, or when tension increases as the tissues
swell.
 This problem, along with the hard, sharp, highly irritating and uncomfortable cut ends, can be
considered a disadvantage.
 Monofilaments of size 7-0 or more are smooth enough and do not suffer these problems.

FIG 148 : (a) and (b) SEM images

of surface and cross-section of
polyamide monofilament suture
(Ethilon).
 Polyester (polyethylene polymer); Mersilene, Ethibond :
 This is a non-absorbable braided polyester multifiber that is uniformly coated with polybutilate
that acts as a lubricant to mechanically refine its physical properties and improve ease of
passage through tissues. Its cut end elicits minimal tissue reaction

FIG 149 : (a) and (b) SEM images of surface and cross-section of polyester multlfilament (Ethibond).
 Polypropylene (polypropylene polymer); Prolene :
 Polypropylene is an isotactical crystalline stereoisomer of a linear hydrocarbonate polymer
that does not allow any saturation.

FIG 150 : (a) and (b) SEM Images of surface and cross-section of polypropylene monofilament (Prolene).
 GoreTex :
 Teflon is an expanded polytetrafluoroethylene (PTFE) suture.
 The carbon fluoride bond is one of the strongest bonds of all organic compounds and makes
GoreTex one of the most inert substances known .
 It is strong and easy to use; and because of its smooth non-porous surface, debris and bacteria
are unable to accumulate on its surface.
 It is available in sizes 4-0, 6-0 and 9-0 as well as CV-4, CV-5 and CV-6 needle shapes.

FIG 151 : SEM Image of surface of polytetrafluoroethylene monofilament (GoreTex).

  Polyglactin :
 It is a rapidly absorbable multifilament suture (7-10 days) that should be used only for suturing
releasing incisions or when the patient cannot return within 72 hours for suture removal.

FIG 152 : (a) & (b) SEM Images of surface and cross-section of multifilament resorbable polyglactin 910 suture.
"Vicryl rapid" is a copolymer of 9 parts of glycolide with one part of lactide.
  Monocryl :
 It is an absorbable monofilament suture.
 It can be used for suturing the releasing incisions also.

FIG 153 : (a) and (b) SEM images of surface and cross-section of monofilament resorbable polyglycaprone (75%
glycolide copolymer. 25% caprolactone) (Monocryl).
 Knots :
 Types Of Knots :
 A slip knot consists of two single overhand knots, but both are made and tied in the same
direction.
 A square/granny knot consists of two single overhand knots, each completed in opposite
directions. It is easy to tie but may loosen when a synthetic or monofilament suture is used.
 A surgeon knot is a modified square knot with two overhand knots, each completed in opposite
directions. It is the most commonly used.
 FIG 154 : Slip Knot

FIG 156 : Surgeon’s Knot

FIG 155 : Square Knot / Granny Knot

 Types Of Suturing :
1. Single Interrupted Suture
2. Interrupted Loop (Interdental)
Suture
3. Vertical Mattress Suture
4. Single Sling Suture
 Single Interrupted Suture

 Used primarily for closure and stabilization

of vertical releasing and relaxing incisions in
full mucoperiosteal flaps and horizontal
incisions in limited mucoperiosteal flap
designs.

FIG 157 : Single interrupted sutures can be used for

both the horizontal
incision and the vertical incision.
 Interrupted Loop (Interdental) Suture

 Used primarily to secure and stabilize the horizontal component of full mucoperiosteal flaps.
 Vertical Mattress Suture

 It’s advantage is that it does not require needle

penetration or suture material being passed
through tissue involved in the incisional wound.

FIG 158 : Vertical mattress suture avoids penetration of

tissues in the incisional wound and supports the
interdental papilla in a coronal direction.
 Single Sling Suture

 Similar to the vertical mattress suture.

FIG 159 : Sling suturing technique

 POST OPERATIVE INSTRUCTIONS
 Do not lift up lip or pull back the cheek to look at where the surgery was done.
 A little bleeding from surgical is normal. This should only last for a few hours.
 A little swelling and bruising face may be evident which may last for a few days.
 Do not drink alcohol or use tobacco (smoke or chew) for the next 3 days.
 Have a good, soft diet and drink lots of liquids for the first few days after surgery.
 Place an ice bag (cold) on face where the surgery was done. Leave it on for 20 minutes and take it off
for 20 minutes. Continue this for 6 to 8 hours.
 Take the prescribed medicines as recommended.
 Rinse the mouth with 1 tablespoon of the chlorhexidine mouthwash twice daily for 5 days.
 Suture removal after 5-7 days by the dental personnel only.
 Maintain post operative follow up recall visits.
 If any problems exists inform and visit your dentist immediately.
 REFERENCES
 Mustafa M., Historical Perspective in Surgical Endodontics, Adv Dent & Oral Health, 2016; 3(5).
 James L. Gutmann, Historical Perspectives on the Evolution of Surgical Procedures in Endodontics,
Journal of the History of Dentistry, 2010; 58(1).
 Dr. Rutika R Naik & Dr. Deshpande M Prashanth, Techniques of root end preparation for the
successful peri-radicular surgery: A literature review, International Journal of Applied Dental Sciences
2016; 2(2): 06-10.
 Enrique M. Merino, Endodontic Microsurgery.
 I. E. Barnes & R. Palmer, Surgical Endodontics A Colour Manual.
 Igor Tsesis, Complications in Endodontic Surgery.
 Kenneth M. Hargreaves & Louis H. Berman, Cohen’s Pathways Of The PUlp, 11th Edition.
 V. Gopikrishna, Grossman’s Endodontic Practice, 14th Edition
 John I. Ingle, Leif K. Bakland & J. Craig Baumgartner, Ingle’s Endodontics, 6 th Edition.
 Syngcuk Kim, Microsurgery In Endodontics, 1st Edition
 Richard Rubinstein, Magnification And Illumination In Apical Surgery, Endodontic Topics 2005, 11,
56–77.
 Gutmann JL, Harrison JW. Posterior endodontic surgery: anatomical considerations and clinical
techniques. Int. Endod J 1985;18:8.
 Dr. Gopikrishna, Dr. D. Kandaswamy, Dr. S. Nandini; Newer Classification Of Endodontic Flaps;
November 2005.
 Sriram Bhat M, SRB’s Manual Of Surgery, 5th Edition.
 Youtube Channel – JCParkland & Dr Stuart Orton-Jones
THANK YOU