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Predictable apical microsurgery (entree) / News / Removal of warm carrier-based products with the Twisted File / Predictable apical microsurgery / The evolution of media in dentistry

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ENDO TRIBUNE
The World’s Endodontic Newspaper · U.S. Edition
JULY 2009

www.endo-tribune.com

VOL. 4, NO. 7

David Rosenberg

Changing technology

Faster version

Endodontist, wife die
in rafting accident

How do you decide
what to participate in?

GuttaFlow® FAST
offers innovative system

Page

Page

2

Predictable apical
microsurgery
Part 1: Preparation of the patient
By John J. Stropko, DDS

Surgery will never replace solid
endodontic principles and should
always be a last resort. Apical microsurgery consists of nine basic steps
that must be completely performed
in their proper order so we can
achieve the desired result for our
efforts.
The nine steps are as follows:
1. Instruments, supplies and
equipment are ready.
2. Patient, doctor and assistants
positioned ergonomically.
3. Anesthetic and hemostasis staging completed.
4. Incision and atraumatic flap elevation.
5. Atraumatic tissue retraction.
6. Access, root-end bevel (root-end
resection, RER, and REB) and crypt
management.
7. Root-end procedures: root-end
preparation (REP).
8. Root-end fill (REF) techniques
and materials.
9. Sutures, healing and post-op
care.

Fig. 1: The Six-Handed Team
approach enables us to maximize
today’s technology today!

Predictable microsurgery requires
the use of an operating microscope
(OM) and a team committed to operating at the highest level. The SixHanded Team approach optimizes
the instruments, equipment, techniques and materials that today’s
level of technology presents for the
benefit of all — especially the patient!
Dr. Berman, an old retired general
surgeon, and one of my senior-year
dental school instructors, would
 ET page 6

Removal of warm
carrier-based products
with the Twisted File
By Richard Mounce, DDS

“Does anyone have any advice on
how to remove Thermafil with twisted files?”
Recently, I received this question
via e-mail from a colleague. Thermafil is a warm carrier-based obturation product of Dentsply Tulsa
Dental Specialties (Tulsa, Okla.).
The Twisted File (TF) is a product of
 ET page 4

Fig 1a, 1b: Clinical cases treated in
the manner described. The Twisted
File (SybronEndo, Orange, Calif.)
was used to remove the plastic Thermafil Carriers (Dentsply Tulsa Dental
Specialties, Tulsa, Okla.).

7

Page

7

AAE names new officers
at 2009 annual session
The American Association of
Endodontists installed the new officers of the AAE Executive Committee for the 2009–2010 term at the
group’s recent annual session in
Orlando, Fla.
• Gerald N. Glickman, DDS,
MS, MBA, JD, was named AAE’s
president. His agenda for the AAE’s
year centers on “Access to Care,”
finding ways to deliver endodontic
care and help people save their
natural teeth. Glickman is professor and chair of the Department of
Endodontics and Director of Graduate Endodontics at Texas
A&M/Baylor College of Dentistry in
Dallas. Long active in leadership
roles for the AAE, he has been a
member of the executive committee since 2005. He also is a diplomate and past president of the
American Board of Endodontics.
• Clara Spatafore, DDS, MS, was
named president-elect. Spatafore is
a full-time private practitioner in
Pittsburgh who also is an assistant
professor of endodontics at Drexel
University’s School of Medicine
and Alleghany General Hospital. A
member of the AAE since 1987, she
has held a variety of leadership
roles with the organization, including secretary and vice president of
its executive committee and director representing AAE District I.

• William T. Johnson, DDS, MS,
was named vice president. Johnson, the Richard E. Walton professor and chair of the Department of
Endodontics at the University of
Iowa College of Dentistry in Iowa
City, has had a long record of service to the AAE. In addition to representing District V on the AAE
Board of Directors, Johnson has
been board liaison to and a member of various AAE committees.
• James C. Kulild, DDS, MS, was
named secretary. Kulild is a professor and director of the Advanced
Specialty Education Program for
Endodontics at the University of
Missouri-Kansas City School of
Dentistry in Kansas City. An AAE
member since 1981, he has represented AAE District III on the AAE
Board of Directors since 2005.
• Robert S. Roda, DDS, MS, was
named treasurer. Roda is an
adjunct assistant professor at Baylor College of Dentistry in Dallas
and a visiting lecturer at the Arizona School of Dentistry and Oral
Health in Mesa. An AAE member
since 1991, Roda has chaired its
Continuing Education Committee
and has served as an associate editor of the Journal of Endodontics
since 2002. ET
(Source: AAE)

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News

ENDO TRIBUNE | JULY 2009

ENDO TRIBUNE
The World’s Endodontic Newspaper · U.S. Edition

Dental Tribune Study Club
develops case studies database
As modern technology advances,
so does the opportunity of using and
sharing data. Nowhere is this truer
than with medical data.
The benefits of providing shared
access to a practitioner’s case studies
are becoming increasingly evident
throughout medical communities,
and especially in dentistry. For dentists, this type of knowledge sharing
has been recognized as a key to
improving their clinical decision
making abilities.
Case studies:
• Allow the application of theoretical concepts to be demonstrated,
thus bridging the gap between theory
and practice.
• Encourage active learning. Dental professionals who learn through
colleagues’ experiences benefit from
exposure to real-world data.
• Provide an opportunity for the
development of key skills such as
communication and problem solving.
• Increase dentists’ enjoyment of
a particular topic, and hence their

desire to learn and improve their
skills.
However, the predominant benefits of sharing case studies are accelerated scientific progress, improved
patient outcomes, reduced research
costs and decreased time in moving
discoveries from paper to actual
practice.
A great case study consists of a
problem, the implementation of a
solution and the results. The problem
should have significant practice
impact for the reader. The implementation demonstrates how the
practitioner resolved the problem.
Finally, the case must be supported
with measurable results: statistics,
photos and even tables when appropriate.
Dental Tribune Study Club (DTSC)
is an online educational platform
where you can not only earn C.E.
credits, but also share your own case
studies and examine those submitted
by other dental professionals from
around the world. Dental Tribune

welcomes case submissions for its
online Case Study Database at
www.DTStudyClub.com. The submission process is easy:
• Become
a
member
of
www.DTStudyClub.com (it’s free!).
• Access “Discussion Groups” and
select the field of dentistry that
applies to your case. From there,
select “Case Study Discussions” and
then select a new thread.
• Now you will have the option of
writing a case description; posting
relevant photos, tables or charts;
adding tags; creating a poll to encourage peer feedback; etc.
Congratulations! Posting cases
couldn’t be easier.
The DTSC Case Studies Database is
constantly growing, with many members contributing cases on a regular
basis. DTSC accepts case submissions
in all areas of dentistry including general dentistry, cosmetic dentistry,
endodontics, implantology, periodontics, orthodontics, dental hygiene and
practice management. ET

Endodontist David Rosenberg
and wife die in rafting accident
By Fred Michmershuizen, Online Editor

David B. Rosenberg, an endodontist with a practice at Vero Beach,
Fla., and his wife, Jean, died in an
accident on June 11, according to a
local media report. An article posted
to the online edition of the Vero
Beach Press Journal reported that
Rosenberg and his wife were killed
in a whitewater rafting accident
while vacationing in the Dominican
Republic.
Rosenberg was highly recognized
as a leading expert in the field
of endodontics. He practiced and
taught endodontic retreatment for
more than 15 years, and he was a
regular presenter at endodontic
meetings throughout the country. He
also offered hands-on conventional
endodontic and re-treatment courses at his practice in Florida.
Fellow specialists who knew
Rosenberg expressed admiration.
“David Rosenberg was an outstanding endodontist who was passionate about our specialty,” said Dr.
Frederic Barnett, editor in chief of
Endo Tribune and chairman and
program director of the IB Bender
Division of Endodontics at the Albert
Einstein Medical Center in Philadelphia, Pa. “He was a true gentleman
and will be missed by the many people that he touched.”
“David was one of the best people
I have ever known, both as a human
being as well as an endodontist,”
said Dr L. Stephen Buchanan. “He
was honest and true, he had his pri-

Dr. David B. Rosenberg was a respected and well-known endodontist.

orities in line, and I couldn’t ask for
a better friend. I first got to know
him as a young endodontist who
looked to me as a mentor, but very
quickly he became mine. Some of
the best things I have learned in my
career were taught to me by him,
and it was always cool to hear his
latest thoughts on procedures. He
definitely thought outside of standard convention with the only rigidly held principles being that the
patient was first, that anything that
could make a procedure more successful was worth the effort, and that
doing things well was its own
reward.”
“Dr. Rosenberg was one of my
closest friends in the business,” said

Jim Kelley of Dental Education Laboratories. “He was a talented clinician and an innovative thinker who
was well respected among his peers.
But above all, Dr. Rosenberg was a
devoted husband to Jean and an
active participant in the lives of his
sons, Eddie and Steven. While we
talked often, business was always
secondary to the stories and adventures he shared with and about his
family.”
Rosenberg was well liked by his
patients. Some of them posted online
comments about him to the
tcpalm.com Web site.
“Dr. Rosenberg did a root canal
for me a few years ago,” one of his
patients wrote. “He got me in at the
last minute and stayed until my root
canal was done, well after 8 p.m. He
could not have been more kind and
professional.”
“This makes me so sad,” another
wrote. “I was in his office a few
months ago. [He was an] excellent
doctor and just a genuinely nice person. My condolences to his kids and
his office staff.” ET

Corrections

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s.rendon@dtamerica.com.

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Frederic Barnett, DMD (Editor-in Chief)
Roman Borczyk, DDS
L. Stephen Buchanan, DDS, FICD, FACD
Gary B. Carr, DDS
Prof. Dr. Arnaldo Castellucci
Joseph S. Dovgan, DDS, MS, PC
Unni Endal, DDS
Fernando Goldberg, DDS, PhD
Vladimir Gorokhovsky, PhD
Fabio G.M. Gorni, DDS
James L. Gutmann, DDS, PhD (honoris
causa), Cert Endo, FACD, FICD, FADI
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Sergio Kuttler, DDS
John T. McSpadden, DDS
Richard E. Mounce, DDS, PC
John Nusstein, DDS, MS
Ove A. Peters, PD Dr. med dent., MS, FICD
David B. Rosenberg, DDS
Dr. Clifford J. Ruddle, DDS, FACD, FICD
William P. Saunders, Phd, BDS, FDS, RCS Edin
Kenneth S. Serota, DDS, MMSc
Asgeir Sigurdsson, DDS
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John D. West, DDS, MSD

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Clinical

ENDO TRIBUNE | JULY 2009

ET page 1

SybronEndo, (Orange, Calif).
It is a fair statement that many of
the general dental clinicians who
use warm carrier-based obturation
in endodontics have never re-treated (removed) them when it is placed
in root canal treatment that fails.
Thermafil is a valid obturation
technique that is supported in its
efficacy by the endodontic scientific
literature. The concept most certainly has its advocates and champions.
This said, aside from the cost relative to other options, removal of
the carrier can, at times, be challenging. This column was written
for the general practitioner to be
exposed to and made aware of the
basic steps involved in retreatment
of warm carrier-based products in
which the carrier is plastic and to
discuss its removal with the TF.
Clinical use of the techniques
described would be best learned in a
continuing education format using a
surgical operating microscope
(SOM) (Global Surgical, St. Louis,
Mo.) beginning with practice in
extracted teeth.
As mentioned, retreatment of
warm carrier-based products can, at
time, be problematic. Carriers that
have been placed with significant
frictional retention into long, narrow and curved canals are more difficult to remove than other such
devices. Metal carriers were utilized
in early warm carrier-based product
versions.
In my clinical experience retreating warm carrier based products,
metal carriers have generally been
easier to remove than the plastic
ones. Whether metal or plastic,
techniques for removal varied from
the use of solvents, such as chloroform to dissolve out gutta-percha
from around the carrier, blended
with Hedström files to lift the carriers. For plastic carriers, a rotary
nickel titanium (RNT) file spinning
counterclockwise, could, in theory,
pick up the carrier and propel it out
of the canal.
Heat could also be used to melt
the plastic carriers to create access
into the canal or alongside a plastic
carrier. Carrier retention is a function of canal preparation as well as
carrier fit. If the canal did not have a
continuous taper, frictional retention of the carrier is more likely
along more of its length.
Using a carrier that is slightly too
large for the prepared canal space
can often have the same effect. Plastic Thermafil carriers will not dissolve in solvents, such as chloroform. Up to this point in time, RNT
instruments have not been able to
predictably machine out the plastic
carriers of warm carrier-based
obturation techniques. The TF, if
used correctly, is the first RNT file
that I have used that can do so with
predictability.
The TF is never cut across its
grain structure in manufacture. The
file is twisted in its manufacture
while in a crystalline phase struc-

Figs. 2a, 2b: Clinical cases treated in the manner described. The Twisted File
(SybronEndo, Orange, Calif.) was used to remove the plastic Thermafil Carriers
(Dentsply Tulsa Dental Specialties, Tulsa, Okla.).

men. No RNT system should be used
beyond the minor construction of
the apical foramen and the TF is no
expectation to this rule.
Usually, it will take approximately two TF instruments (or one) to
machine a plastic carrier out of the
canal. When the carrier has been
machined through and the clinician
reaches the apex, if a film is taken,
usually, the clinician can see small
fragments of the carrier at the lateral root walls of the canal.
Use of solvents (most often chloroform) and Hedström files to tug
these fragments out of the canal is
simple, predictable and can render
the entire canal free of any substantial gutta-percha or remnants of the
plastic carriers. After carrier
removal, optimally, the clinician
would gauge the minor constriction
of the apical foramen (use a hand K
file to determine the initial diameter
of the MC) and then finalize the
preparation to the master apical
diameter.
While it is empirical, it is a common technique to gauge the apex
and finalize the canal preparation to
three sizes larger than the first file
that bound at the MC. Inherent in
this recommendation is the awareness that the MC is not being
enlarged or transported and that the
canal is being shaped up to the MC
and not beyond. In essence, the MC
that is present is left alone and not
moved, enlarged or altered in any
way.
A clinically relevant discussion of
plastic carrier removal has been
provided with the goal of informing
general practitioners of common
methods of carrier removal using
new and innovative technology in
the form of the Twisted File.
I welcome your feedback. ET

Fig. 3: The Twisted file (SybronEndo, Orange, Calif.)

ture known as R phase, which is an
intermediate phase between austenite and martensite (the resting
phase of nickel titanium and the
phase present under stress during
function, i.e., rotating through a curvature during canal shaping). In
addition to twisting, TF manufacture is finalized with a final deoxidation process that maintains the
files’ surface hardness and sharpness of the cutting edges.
These properties make the TF
very different in its capabilities relative to other RNT instruments that
are ground from a nickel titanium
wire. One of these functional capabilities is the ability of the TF to
grind through plastic carriers. Clinically, depending on the size of the
canal to be retreated, usually, either
a .08 or .10 TF instrument will be
used for this purpose. The TF is
used at enhanced rotational speeds
for this purpose, usually 900-1200
rpm. It is designed to be used in one
canal or one tooth, be that one canal
or five canals.
In plastic carrier removal, the TF
is advanced passively into the carrier as far as the carrier will allow it.
“Passive” is the operative word; if
the TF does not want to advance

into the plastic carrier slowly and
gently, the next smaller TF is used.
No gutta-percha solvent is used for
this first step; this initial insertion is
done dry in the canal, optimally
through the surgical operating
microscope (SOM) (Global Surgical,
St. Louis, Mo.).
After the initial TF insertion, irrigant can be placed in the canal, if
the clinician opts to use irrigant,
optimally 2 percent chlorhexidine
(CHX). As mentioned, when the first
TF inserted will not advance passively through the plastic carrier
any further, it is withdrawn, the
CHX is added (as and if desired) and
the remainder of the carrier
removal is performed.
If the same TF taper will allow
passive advancement, it can be reinserted; if it will not, the next smaller
TF is inserted. It is essential that the
clinician be cognizant of two things
in the TF’s use for this purpose:
1) taking care not to strip the furcation of the root, in essence to not
allow the TF to be pushed toward
the furcation and/or preferentially
remove dentin toward the furcation.
2) The length of the canal must be
kept in mind to prevent the TF from
being taken beyond the apical fora-

About the author

Dr. Richard Mounce lectures globally and is widely published. He is in
private practice in endodontics in
Vancouver, Wash. Mounce offers
intensive customized endodontic
single-day training programs in his
office for one to two doctors at a time.
For more information, contact
Dennis at (360) 891-9111 or write
RichardMounce@MounceEndo.com.

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Clinical

ENDO TRIBUNE | JULY 2009

ET page 1

begin each general surgery lecture
by tapping the lectern with his pencil, and after getting our attention, he
would say, “Treat the tissues with
tender loving kindness and they will
respond in a like manner.” I have
heard those very words many times
while performing apical microsurgery. It is truly a gentle technique
when the steps are followed in the
proper order.

Fig. 2: The six-handed team creates
an environment for ergonomics and
the most efficient use of time.

Fig. 3: Smaller straight Tempur pillow can be used for the neck, lower
back, or knees to give added support
for patient comfort.

Fig. 4: Patient’s head and chest are
draped and the patient’s vital signs
are constantly monitored using a Pulsoximeter.

Fig. 5a: Modified Monoject needle
bent similar to the ultrasonic tip used
for the REP.

Preparation of the patient for
predictable apical microsurgery
A thorough past medical history and
dental examination, using as many
diagnostic aids as possible, is a
requirement for a predictable microsurgical event. Being thorough can
also avoid unfavorable experiences.
For example, if the patient, or the
physician, states he or she is sensitive or allergic to epinephrine, to any
degree, the author highly recommends that apical microsurgery not
be performed. One of my golden
rules of thumb is, “No epi, no surgery
… Period!” If the doctor chooses to
proceed with the microsurgical procedure, it will be exceptionally more
difficult for both the doctor and the
patient.
The technology that exists today
presents us with so much more
presurgical information than was
available even a few years ago, and
the recent advances should be
included in the diagnostic process
whenever possible. A good example
of current technology is cone-beam
computed tomography (CBCT). The
radiological images we have been
using for many years were the best
we had, but were very limited. Now,
CBCT enables the microsurgeon a
view of all angles of areas of concern
in the maxillofacial region and supplies much of what was missing in
the field of dentistry.1
The preparation of the patient not
only takes the patient into consideration, but also the entire surgical
team. The microsurgical protocol we
teach involves four people: the doctor (pilot), the scope assistant with
the co-observer oculars for evacuation and retraction (co-pilot), the
surgical assistant using the monitor
as a visual reference (flight director)
and the patient (first-class passenger).
The medical history and all necessary pre-medications are reviewed
with the patient to be sure that the
latter are taken at the appropriate
times before the surgery appointment. The patient is also instructed
to rinse with Peridex and take an
anti-inflammatory (preferably 600
mg of Motrin, if no allergies are present) the night before and also on the
morning of the surgery. At the time of
the appointment and before the
patient is seated, he or she is once
again asked to rinse with Peridex.
The dental chair should allow the
patient to recline comfortably and
even allow the patient to turn to one
side or another. Small Tempur pillows placed beneath the patient’s
neck, small of the back or knees,

Fig. 5b: Set of three Stropko Irrigators with a variety of tips in place for
possible use during the surgical procedure.

Fig. 6a: Due to the ballooning and
blanching effect, the muco-gingival
line becomes more pronounced during the hemostasis staging injections.

Fig. 6b: When the buccal portion of the
hemostasis staging is complete, the
operator can easily plan the incision.

Fig. 7: Rinsing the entire surgical site
with Peridex.

make a big difference when used.
After the patient is completely
comfortable in the chair, he or she is
coached on how to make slow and
small movements of the head, if necessary during surgery. The patient is
appropriately draped for the surgery.
It is especially important to wrap a
sterile surgical towel around the
head and over the patient’s eyes for
protection from the bright light of the
microscope and any debris from the
surgical procedure.
An important psychological point
is being sure to not tell the patient he
or she “can’t move”! To an already
tense patient, saying “don’t move”
would probably cause unnecessary
apprehension, stress or panic. In
more than 500 surgeries, I’ve only
had one patient that didn’t hold nice
and still during the procedure once
he was relaxed and had profound
anesthesia.
Now is the time for the surgical
team to get comfortable with the
position of the patient, the microscope, endoscope and associated
equipment. Modern OMs have many
features to enhance comfort and pro-

ficiency during their use. Accessories
like beam splitters, inclinable optics,
extenders, power focus and zoom,
variable lighting and focal length,
etc., all contribute to ease of use,
ergonomics and proficiency for the
entire surgical team. The mutual
comfort of the patient, the surgical
assistants and the doctor is of the
utmost importance. The microsurgical technique may take an hour or
more, so unnecessary movements or
adjustments for comfort’s sake during the operation may cause considerable inconvenience.
The doctor’s surgical stool must
have adjustable arms to allow the
elbows to support the back and serve
as a reference point, or fulcrum, if
the doctor has to reach for an instrument during the procedure. Ideally,
neither the doctor nor the scope
assistant have to remove their eyes
from the oculars of the OM during
the entire operation. The task of
directing the whole operation
belongs to the second surgical assistant. The second surgical assistant is
the choreographer for the procedures that take place with the OM.

He or she is in a position to observe,
coach and/or pass instruments to
either the doctor or the scope assistant. The second surgical assistant
can see the entire surgical environment and is the only one on the team
that has an overview, to keep track of
everyone’s needs. It is important that
all possible surgical instruments are
organized for ease of access during
the operation.
While the anesthesia is getting
profound, this is a perfect time to
modify the needles that will be
placed into the tips of the Stropko
Irrigators (www.stropko.com) for
use during the surgery. The notched
ends of 25 gauge Monoject Endodontic irrigating needles (SybronDental)
are removed by bending with Howe
Pliers and placed into the end of the
Stropko Irrigators. One tip is used
with an air/water syringe and the
other tip is used on the dedicated
“air-only” syringe (DCI). The
endodontic irrigating needles are
then bent in the same configuration
as the ultrasonic tip that is being
used for the root-end preparation.
After the needle is bent, the
ergonomics of the bend can be verified quickly and easily because the
patient is in the proper position and
so is the doctor.
Optimally, there are three Stropko
Irrigators available for any surgical
procedure: one three-way syringe fitted with a larger blue tip (SybronEndo) for more general flushing of the
surgical area (we call it the “Big
John”); another three-way syringe
fitted with a modified 25-gauge needle for more precise cleaning and
drying (“Little John”); and one with
an “air-only” syringe, fitted with a
modified 25-gauge needle, for precise and dependable drying of the
specific area without worry of moisture contamination.
Also, because the lumen of the
high-speed evacuator tips (Young’s
Surgical) is small, be sure to have
extra tips readily available if one
should become clogged. A beaker of
water should be available so the
scope assistant can occasionally
clear the evacuator system of blood
and tissue debris from the evacuator
tip.
After topical anesthetic is placed,
local anesthesia is started using less
than one carpule of warmed 2 percent lidocaine containing 1:50,000
epinephrine. This small amount is
done to anesthetize the injection
sites that will be used next for the
blocks and infiltrations. The 1:50,000
lidocaine is used prior to the 0.5
percent bupivacaine (Marcaine)
because the Marcaine tends to burn
upon injection, whereas the lidocaine is much friendlier to the
patient. This is then followed with
one or two 1.8 cc carpules of warmed
Marcaine for nerve blocks and/or
infiltrations. All anesthetic is
warmed and injected very slowly to
avoid any unnecessary trauma to the
tissue, which also creates much less
discomfort for the patient.
After the completion of adminis ET page 7

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Industry 7C

ENDO TRIBUNE | JULY 2009

GuttaFlow
FAST needs
no heating
Coltène/Whaledent recently
announced the introduction of
Hygenic GuttaFlow® FAST, the fast
setting (eight to 10 minutes) version of the innovative GuttaFlow
obturation system. GuttaFlow is
the first flowable gutta-percha
obturation system that combines
gutta-percha and sealer in one
material.
This self-curing, injectible system works at room temperature,
ensuring an excellent seal without the shrinkage that occurs
with heated obturation systems.
With the excellent flow and sealing properties of GuttaFlow, condensation is not required.
GuttaFlow and GuttaFlow FAST
come in single unit dose capsules
that deliver a consistent dosage
and minimize contamination. It is
also radiopaque and can be
removed easily should retreatment or post placement become
necessary. Faster, easier and
more economical than heated,
injectible obturation systems,
GuttaFlow® is also biocompatible,
providing dentists with a safe,
reliable and time-saving root
canal obturation system.
For additional information,
call (800) 221-3046 or visit
www.coltenewhaledent.com. ET

ET page 6

tering the local anesthetics, it is time
to perform hemostasis staging using
2 percent lidocaine containing
1:50,000 epinephrine. It has been
shown that 2 percent lidocaine containing 1:50,000 epinephrine produces more than a 50 percent
improvement in hemostasis compared to 2 percent lidocaine containing 1:100,000 epinephrine.2
While keeping the bevel of the
needle toward the bone and directed
apically toward the root ends, small
amounts of 2 percent lidocaine
1:50,000 are slowly injected into the
free gingival tissue in two or three
sites to the buccal of each tooth (MB,
B, DB), approximately 3 mm apical to
the muco-gingival line. Slow injection of just a few drops of the anesthetic causes a slight “ballooning”
and blanching of the tissue in the
immediate area. This is an important
step because it causes the muco-gingival line to become more pronounced, allowing the operator to
have better vision, resulting in more
accuracy with the following hemostasis injections.
As the anatomy of the tissue
unfolds during the injections, the
operator should begin visualizing
and planning the incision. The
amount and nature of the attached

The evolution of media in dentistry
In the ever-changing world we live
in, technologies are evolving at a pace
that surpasses most of our learning
curves.
Blogs, social networking sites, message boards, Twitter, Facebook,
MySpace and many more interactive
media are becoming a part of our
every day lives.
Realistically, we must carefully
choose which of these multimedia
outlets we participate in or, otherwise,
there would be no time left in the day
for work, friends or family.
When choosing a multimedia
forum, one must ask oneself the following important question: “How is
this technology improving my life?”
As a dental professional in the year
2009, there are many new technologies being introduced to our industry
at a rapid pace. What was once a
media-shy industry has evolved to the
tune of more than 1,000 media forums
aimed at dental professionals. With all
of these sites claiming to help you —
how can one reasonably choose which
to join and participate?
Recently, a new dental multimedia forum was launched called
www.endomailmessageboard.com.
You may ask what makes this site any
different from the others. Well, the
answer is the community response to
the site has been overwhelmingly positive. Endomailmessageboard currently has more than 800 members, all
of whom joined after the inception
date of September 2008.
The new online community offers
an interactive online forum focused

gingiva is an important consideration whether a full sulcular or a
mucogingival (Leubke-Oshenbein)
flap is used. In general, a full thickness, sulcular flap is routinely used
unless esthetics is a concern and
there is an adequate zone of attached
gingiva present. To ensure optimum
hemostasis, the lingual tissues
should also be infiltrated.
If doing surgery on the posterior
quadrant of the mandible, special
attention should be given to the apical region of the mandibular second
molar. On occasion, a small foramen,
called the foramen coli, may be present. The foramen coli, if present,
contains an ascending branch of the
mylohyoid nerve. This added step,
“lingual hemostasis staging,” can
contribute to more profound anesthesia, enhance crypt management,
and, as a result, contribute to a more
predictable event with less stress for
the entire team.
If the surgery is to be performed
on the maxillary, the patient is
instructed to close on approximately
eight layers of sterile gauze, (four
2x2’s folded over once) for stability of
the jaws and to keep any debris from
inadvertently entering the oral cavity. A single piece of a sterile 2x2 is
also gently placed distal of the
tooth/teeth to be operated on. If the
surgical procedure is on the
mandible, especially when a full sul-

Unlike traditional blogs
and message boards,
endomailmessageboard
truly utilizes
modern technology
while remaining
user-friendly.
on excellence in dental education.
Recently, the multimedia site has
enhanced its online features by offering dentists free continuing education
credits to its members.
Dentists will be able to print their
certificates immediately with a passing grade of 70 percent, and the entire
test history will be stored for their
record-keeping convenience.
In addition to offering free and
innovative continuing education, the
message board is a place where dentists can come together to share ideas,
post questions, gain peer advice and
learn about industry news in a nonthreatening environment.
Unlike other message boards,
endomailmessageboard does not
allow its members to have anonymity.
Further, members are held to humane
standards of professionalism. The
Web site was created so dentists can
safely post cases and questions and
gain constructive advice from their
peers without fear of embarrassment
or ridicule.
Members come from countries all
around the world, creating a global
community of dental professionals. A
dentist from India can post a case and

cular flap is used, the operator may
want to make the incision with the
mouth slightly open before placing
the gauze.
In either case, with the aid of the
OM and using a pre-filled 3 ml.
syringe fitted with a 20-gauge needle, the entire surgical site is rinsed
with Peridex to make sure the area is
clean of debris and free of plaque
before the incision is made. The surgical site is now ready for the next
important step in the procedure: Flap
design, the incision and atraumatic
flap elevation.
ET
(This is part one in a six-part series
on apical microsurgery. Look for part
two in the next issue of Endo Tribune.)

References
1. Thomas SL, Angelopoulos C.
Contemporary Dental and Maxillofacial Imaging, Dent Clin North Am
2008; 52: xi
2.
Buckley JA, Ciancio SG,
McMullen JA. Efficacy of epinephrine concentration in local anesthesia during periodontal surgery. J
Periodontol 1984; 55: 653–57
3.
Harrison JW, Jurosky KA.
Wound healing in the tissue of the
periodontium following periradicular surgery II. The dissectional
wound. J Endod 1991; 17 (11): 544–52

receive feedback from his or her peers
in Saudi Arabia or Ireland. The sense
of globalization is present throughout
the site. Dentists quickly realize that
clinical cases do not differ from country to country.
Endomailmessageboard
also
allows dentists to upload X-rays,
videos, documents and 3-D images
and write private messages or provide
content to share among peers.
The message board encompasses
technology to create a modern and
efficient multimedia forum. Unlike
traditional blogs and message boards,
endomailmessageboard truly utilizes
modern technology while remaining
user friendly.
Recently endomailmessageboard
conducted a survey of its members.
The feedback that the Web site
received was overwhelmingly positive. The members all agreed that the
site offers them a safe haven on the
Internet where their clinical questions
are answered professionally and in a
timely fashion. The members also
stated that the site was unlike any others that they have experienced as dental professionals.
ask
yourself,
“Is
the
So,
technology I am using today improving my life?” If you even have
a moment of hesitation, you
should take the time to view
www.endomailmessageboard.com.
It may be the vehicle you need to
enhance your clinical skills. ET
(Source: Essential
Dental Systems)

About the author
John J. Stropko received his DDS from
Indiana University in 1964, and for 24
years
practiced
restorative
dentistry. In
1989, he received a certificate for
endodontics
from Boston
University
and recently
retired from
the private
practice of endodontics in Scottsdale,
Ariz. Stropko is an internationally recognized authority on micro-endodontics.
He has been a visiting clinical instructor
at the Pacific Endodontic Research
Foundation (PERF), an adjunct assistant
professor at Boston University and an
assistant professor of graduate clinical
endodontics at Loma Linda University.
His research on “in-vivo root canal morphology” has been published in the
Journal of Endodontics. He is the inventor of the Stropko Irrigator, has published in several journals and textbooks
and is an internationally known speaker. Stropko has performed numerous
live micro-endodontic and micro-surgical demonstrations.

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