Endo Tribune U.S.
Beyond endodontics: Roots Summit 2010 / Apical microsurgery: access and crypt management (Part 3 of 6)
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[1] =>
ENDO TRIBUNE
The World’s Endodontic Newspaper · U.S. Edition
July 2010
www.endo-tribune.com
Vol. 5, No. 7
Beyond endodontics:
Roots Summit 2010
By Claudia Salwiczek, Managing Editor,
Dental Tribune International
What do Barcelona and endodontics have in common? For me,
the answer was nothing, until last
week’s Roots Summit. From now on,
I will forever connect Gaudí, paella
and La Sagrada Família with root
canals.
It is certainly not an exaggeration
to say that the Roots Summit 2010
had all of those lucky enough to
attend falling in love with endo all
over again.
Organized by Drs. Noemí Pascual
and Nuria Campo and their team,
the meeting was a grand success.
Long hours in the dark yet always
crowded lecture hall, despite the
perfect weather, were followed by
a wonderful social program with a
distinct Spanish touch.
Dr. Fred Barnett (editor in chief
of Endo Tribune), who lectured
on “Trauma Injuries: Long-Term
Treatment Planning Based on Dx
and Pulpar Regenerative Technique,” commented: “Congratulations to Nuria and Noemí for organizing a fantastic Roots Summit.
The venue was awesome and the
lectures top notch. Roots should be
proud of its efforts.”
The impressive list of international speakers included Dr.
Giusseppe Cantatore from Italy,
Drs. José María Malfaz and Enrique
Martínez Merino from Spain, and
Drs. Hans-Willi Herrmann and Jörg
Schröder from Germany, to name
a few.
Dr. Sashi Nallapati held two
very interesting lectures on rare
g ET page 2C
Dr. José Maria Malfaz during his lecture on ‘Applications of Volumetric Tomography
in Endodontics: CBCT.’ (Photos/Claudia Salwiczek, Dental Tribune International)
Apical microsurgery: access and crypt management
Part three of a six-part series
By John Stropko, DDS
In Parts 1 and 2 (available online
at www.dental-tribune.com/articles/
content/scope/specialities/region/usa/
id/929, I discussed the preparation of the
patient, the incision and atraumatic flap
elevation. These are the first three steps
necessary to perform predictable apical
microsurgery.
As was mentioned earlier, it is of
utmost importance that all steps are
done completely before proceeding to the
next step. If a step is omitted, or not done
completely, the next step will be difficult,
if not impossible, to do properly. The
operation will develop into a stressful
experience for the patient, the staff and
the clinician with an end result not as
desirable or predictable.
If all of the steps are completed as outlined, all procedures can be performed
without stress, and a favorable postoperative result can be expected. I have
completed hundreds of apical microsurgical operations and all results were
the same with just a few exceptions. The
technique is very gentle and predictable,
if all of the steps are followed without
compromise.
After the properly designed flap
has been atraumatically reflected and
retracted, the access preparation is
ready to begin. Some important considerations are:
1.) How much bone exists on the
buccal aspect of the root undergoing
surgery? If there is total dehiscence,
guided tissue regeneration has to be
considered. Ideally, there should be at
least 3–4 mm of healthy, intact crestal
buccal bone remaining after the access
preparation is completed (Fig. 1).
2.) How much of the apex can be
beveled or resected? Usually, there is an
adequate amount of root length to work
with. The shorter the root, the more
conservative the operator will have to
be when beveling, and the closer the
bevel should be to 0 degrees so less
removal of the root end is possible.
If an exceptionally long post is present, that is closer to the apical terminus
than desired, not as much of the root
end can be resected. Or, if the periodontal bone level is less than desired, a
more conservative amount of apical root
structure should be removed to preserve
as much crown/root ratio as possible.
Fig. 2a: The Impact Air surgical
handpiece.
Fig. 1: An adequate amount of crestal
bone should remain between osseous
crest and the coronal extent of the crypt.
(Photos/Provided by Dr. John Stropko)
Fortunately, the operating microscope (OM), and/or the Endoscope (JedMed), allows the operator the luxury of
being ultra-conservative when necessary.
The access to the root end is done
most effectively with a high-speed handpiece that has no air exiting the working end (Fig. 2a). The usual air-driven
handpiece does have air at the working
end and using it could result in an air
embolism. It is important to use as much
water coolant as vision will permit to
maintain the moisture in the tissues.
Fig. 2b: The three surgical burs.
Using a fine stream of water from the
Stropko Irrigator fitted with a 27-gauge
needle, the scope assistant can keep the
area moist and evacuate excess fluids
at the same time. The initial access and
g ET page 6C
[2] =>
2C
News
Endo Tribune | July 2010
ENDO TRIBUNE
f ET page 1C
and challenging cases: “Dens
invaginatus: Treatment options”
and “Three canal premolars: An
endodontic challenge.” Many in
the audience had never encountered such cases and, thus, were
absorbed in these presentations.
Dr. Marga Ree from the Netherlands held two very entertaining
lectures on the “Disassembly of
root-canal treated crowned teeth”
and “Fibre posts and adhesive
build-ups.” She began her first
lecture with limited visibility —
she had forgotten to bring her
glasses — and aching feet.
However, without further ado,
Ree sent her husband to their
hotel room to collect her glasses
and more comfortable shoes. He
promptly returned, carrying a big
bag filled with an estimated 10
pairs of shoes, which he then set
out on stage, one by one. Needless
to say, the audience was roaring
with laughter at this point.
In fact, many of the lectures
were very entertaining and
of extremely high quality with
regard to the content as well as
presentation.
“It was great to see presentations that staggered me with
the quality of the material and
the multimedia that were shown,”
said Dr. Glenn van As, who lectured on “Microscope-centered
practice: Ergonomics and documentation.” “Video through the
operating microscope and still
photos from some of the experts
were incredible. It is impressive
to see the quality of the work that
these teachers and talented clinicians can provide in a humble yet
confident manner.”
The meeting was sponsored by
major industry players, such as
VDW, Zeiss, DENTSPLY Maillefer,
SybronEndo Europe and Kodak.
Dr. John Schoeffel from the
United States, who introduced
EndoVac — an endodontic irrigation technology system — in his
lecture, also presented the product to interested attendees at the
Discus booth.
EndoVac enables safe irrigation to apical termination with an
abundant supply of fresh irrigant.
Unlike positive pressure systems
that use cannulas to deliver irrig-
ET
The World’s Endodontic Newspaper · U.S. Edition
Publisher & Chairman
Torsten R. Oemus
t.oemus@dental-tribune.com
Vice President Global Sales
Peter Witteczek
p.witteczek@dental-tribune.com
Chief Operations Officer
Eric Seid
e.seid@dental-tribune.com
Group Editor & Designer
Robin Goodman
r.goodman@dental-tribune.com
Editor in Chief Endo Tribune
Frederic Barnett, DMD
BarnettF@einstein.edu
Above and below, participants during Dr. Glenn van As’ microscope
hands-on course. van As also lectured on ‘Ergonomics and Documentation
in the Microscope Centered Practice.’
Managing Editor/Designer
Implant, Endo & Lab Tribunes
Sierra Rendon
s.rendon@dental-tribune.com
Managing Editor/Designer
Ortho Tribune & Show Dailies
Kristine Colker
k.colker@dental-tribune.com
Online Editor
Fred Michmershuizen
f.michmershuizen@dental-tribune.com
Account Manager
Humberto Estrada
h.estrada@dental-tribune.com
Marketing Manager
Anna Wlodarczyk-Kataoka
a.wlodarczyk@dental-tribune.com
Marketing & Sales Assistant
Lorrie Young
l.young@dental-tribune.com
C.E. Manager
Julia Wehkamp
j.wehkamp@dental-tribune.com
Dental Tribune America, LLC
213 West 35th Street, Suite #801
New York, NY 10001
Tel.: (212) 244-7181
Fax: (212) 244-7185
ants into the canal, the EndoVac
is a true apical negative pressure
system that draws fluid apically by
way of evacuation.
“It’s not often that meetings
inspire and rejuvenate people and
make them look forward to future
meetings,” Nallapati commented.
“To me, certainly, this Roots Summit has done all that. And that is a
testimony to the wonderful effort
of Nuria, Noemí and their team.”
Attendee Dr. Mahalaxmi Sekar
agreed, saying that he pitied all
those who had missed this event
Corrections
Endo Tribune strives to
maintain the utmost accuracy in its news and clinical reports. If you find
a factual error or content that requires clarification, please report the
details to Managing Editor
Sierra Rendon at s.rendon@
dental-tribune.com.
International Editor Endo Tribune
Prof. Dr. Arnaldo Castellucci
Tell us
what
you
think!
in Barcelona.
A majority of the lectures, for
which continuing education credits can be obtained, were recorded
live and will be made available for
review on www.dtstudyclub.com.
For more information on how to
register and how to obtain credits,
contact Julia Wehkamp at julia.
wehkamp@dtstudyclub.com.
The date and venue for next
year’s meeting are yet to be decided. But one thing is for sure: many
2010 attendees are counting down
the days. ET
Do you have general comments or criticism
you would like to share? Is there a particular topic you would like to see more articles
about? Let us know by e-mailing us at
feedback@dental-tribune.com. If you would
like to make any change to your subscription
(name, address or to opt out) please send us an
e-mail at database@dental-tribune.com and
be sure to include which publication you are
referring to. Also, please note that subscription
changes can take up to 6 weeks to process.
Published by Dental Tribune America
© 2010 Dental Tribune America.
All rights reserved.
Dental Tribune America makes every effort
to report clinical information and manufacturer’s product news accurately, but cannot
assume responsibility for the validity of product claims, or for typographical errors. The
publishers also do not assume responsibility
for product names or claims, or statements
made by advertisers. Opinions expressed by
authors are their own and may not reflect
those of Dental Tribune America.
Editorial Advisory Board
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
William “Ben” Johnson, DDS
Kenneth Koch, DMD
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
Yoshitsugu Terauchi, DDS
John D. West, DDS, MSD
[3] =>
x 3B
ENDO Tribune | June 2010
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[4] =>
4B
Clinical
Endo Tribune | June 2010
[5] =>
ENDO Tribune | June 2010
Opinion 5B
[6] =>
6C
Clinical
Endo Tribune | July 2010
f ET page 1C
apiection can be accomplished with
just three surgical length burs: the Lindemann bone bur, a #6 round bur and
an 1171 fissure bur (Fig. 2b). There are
basically two different ways to begin the
access:
1.) Estimate the amount of the apex
to be resected and, with a Lindemann
bone-cutting bur, remove the apex and
prepare the access opening in one general step. If there is any portion of the
apex remaining in the crypt, it is curretted out and the access is more or less
complete.
2.) A more accurate procedure is to
estimate the location of the apex. Then,
using a #6 surgical length, round bur,
slowly and gently remove the bone
overlying the buccal surface of the root.
When the buccal surface of the apex is
uncovered, bone is removed until the
coronal limit of the crypt is established
and the general outline of the apex is
readily observed and can be apiected
at this time. Often, especially with larger periapical involvement, the lesion
can be curetted and the entire apex
exposed. If the lesion is more palatal or
lingual, the root apex may prevent the
necessary access for curettage and will
have to be partially beveled or resected
as part of the access process.
A thorough curettage is important
because it is the first stage of achieving
hemostasis from within the crypt. In
general, if all of the granulation tissue
is removed, the amount of hemorrhage
will be greatly reduced, the management of the crypt is easier to accomplish
and good visibility can be restored. This
technique takes more time but results
in better visibility and the ability to be
more precise with the initial apiection.
The finished bevel will be discussed in
detail later in the article.
In general, a biopsy should be performed on all tissue removed from the
body. We are usually quite confident of
the pathological diagnosis of the LEO,
but my feeling is even if the odds are
1 in 100,000 that we are incorrect, no
chances should be taken and a biopsy
should be taken on a routine basis.
The final dimension of the access
opening varies and is dependent on
several factors:
1.) The size and position of the lesion.
If the lesion is larger, the access will of
necessity be larger in order to perform
a complete curettage.
2.) The position of the apex determines the size of the access. The more
lingual the apex, the more overlying
bone has to be removed and the larger
the access has to be for good visibility.
3.) The access has to be large enough
to allow the instruments room to prepare the apical canal system without
inhibiting their freedom of movement.
The larger the instruments used, the
larger the access must be.
4.) The thickness of overlying bone
is also important. If the buccal plate is
thick, a wider access is necessary to
eliminate a “tunnel effect” so vision is
not compromised.
5.) The experience and ability of
the surgeon, and equipment available,
is a great determinant on how large
the access will need to be. I use both
an Endoscope and the OM when performing apical microsurgery. On some
Fig. 3: A slightly ‘streaked’ piece of
Telfa pad to be placed against the
bony floor of the crypt.
Fig. 4: Only a small amount of ferric
sulfate is used on the micro applicator.
Fig. 5: A brownish-black coagulum
is formed when the ferric sulfate
contacts blood.
Fig. 6: The Telfa pad should be
replaced, as necessary, to maintain
good light reflection in the crypt.
occasions, the Endoscope permits a
better view of the surgical site due to
increased lighting and magnification. It
also increases the ability to view previously difficult, and sometimes impossible, areas to see with the OM. The
extent of a defect or existing anatomical variations that are lingual to the
involved root end are typical examples
of the value of also having an Endoscope during microsurgical procedures.
The management of the crypt is one of
the most important steps, and the operator should take as much time as necessary to achieve the desired result. The
clean and well-managed crypt is essential for good visibility and proper use of
the retrofill materials. Ferric subsulfate
(Monsels Solution, Cutrol), calcium sulfate (Capset, SurgiPlaster), Telfa pads and
epinephrine-soaked pellets (Epidry from
Pascal) are the most commonly used and
effective agents for this purpose.
After all granulation tissue and other
debris have been thoroughly removed
from the crypt, hemostasis is often
achieved as a result of proper “hemostasis staging injections” discussed
previously. If that is the case, only an
appropriately sized piece of Telfa pad
lining the floor of the crypt is necessary
to enhance lighting. However, this is not
always the case and even slight bleeding
must be addressed.
If the crypt exhibits slight hemorrhaging, the tissue surface or piece of
Telfa trimmed to the correct size to fit
can be lightly streaked with Monsels
Solution and pressed into the floor of
the crypt for a short period of time until
the hemorrhaging is controlled (Fig. 3).
If there is moderate hemorrhaging,
the Monsels Solution is carefully applied
with a micro applicator (Ultradent)
directly to the problem area in the floor
of the crypt. Keep in mind that only a
small amount is necessary (Fig. 4).
When ferric sulfate is used to achieve
hemostasis, a thick brownish-black
coagulum will usually result (Fig. 5).
The resultant coagulum can be easily
removed from the crypt with a clean
Micro-applicator (Ultradent), gently
flushed with water using a larger tip
on a Stropko Irrigator as the assistant is
evacuating any debris during irrigation
of the crypt. The process is repeated
until the bleeding is controlled. As soon
as there is complete control of all bleeding in the crypt, the Telfa should be
removed and replaced with a fresh
piece so there is as much “white” surface as possible to facilitate light reflection and enhance vision.
As long as the coagulum resulting
from the use of Monsels Solution has
been cleaned out of the crypt after the
completion of the surgery, its use has
not been shown to affect the healing
process.1
Caution: All forms of ferric sulfate
must be kept well within the confines
of the crypt. It has an extremely low pH
and will instantly chemically cauterize
anything it touches. The buccal plate of
bone, the periosteum, soft tissue and the
Scheniderian membrane should always
be avoided! It is important to keep in
mind that “If a little bit is good, a lot is
not better!” Use only small amounts on
the end of an applicator because a small
amount goes a long way. (Fig. 4)
Note: There are two popular forms
of ferric sulfate: Monsels Solution has a
concentration of 72 percent and Cutrol
is 53 percent. I like the Monsels Solution
because it is very effective, readily available and less costly to use.
On a few occasions, severe hemorrhaging occurs. This can be a result
of inflammation, a severed interdental artery or a compromised clotting
mechanism.
At any rate, when the blood flows
faster than the evacuator can remove it,
there is good reason for a little excitement and fast action! The first thing
to do is to apply pressure over the
crypt with a finger. This will stop the
hemorrhaging long enough to calmly
prepare the next few steps. In a low and
controlled voice, instruct the assistant
to insert a bigger tip into the evacuator
and hold it close to the crypt. If after
removing your finger, the hemorrhaging has not subsided, quickly replace
your finger over the crypt as before.
It is a good idea at this time to
take a radiograph and clinically reevaluate the surgical area to make sure
no unforeseen anatomical structures
(mandibular canal, palatine artery, etc.)
have been infringed upon.
Now have your assistant take a piece
of sterile cotton roll and make a “cotton
plug” large enough to completely fill the
crypt, lightly streaking the tissue surface
with Monsels Solution and insert into
the crypt, holding it firmly in place with
your finger for a minute of so.
After a few minutes, the cotton “plug”
can be safely removed and you can proceed without undue concern. A gentle
irrigation with the Stropko Irrigator
will remove most of the dark-colored
coagulum. The above technique has
worked all three times I found myself
in that situation. In two of my cases, an
interdental artery was the cause and the
other was highly inflamed granulation
tissue remaining in the crypt.
If hemorrhaging occurs on the surface of the exposed buccal plate, a
Touch and Heat (SybronEndo) can be
used. The scope assistant can evacuate the “bleeder” with a small surgical
tip, so its exact source can be determined, and the Touch and Heat can be
used to effectively cauterize it. After the
hemorrhaging is completely controlled
and the crypt relatively cleansed of the
coagulum, a fresh piece of Telfa should
be placed over the internal surface of
the crypt (Fig. 6). Keep in mind when
using the OM that light and dryness are
the most important factors for good visibility. Note: Never proceed to the next
step until total crypt management has
been accomplished.
Once the crypt management is completed, the clinician can proceed to
refinement of the bevel and preparing the retropreps with confidence and
good visibility. At the end of this step,
all hemorrhaging should be controlled;
the grossly resected apical end of the
root should be easily seen; and the floor
of the crypt should be covered with a
clean, white piece of Telfa. An apical
microsurgeon’s dream! ET
* References available upon request
from s.rendon@dental-tribune.com.
** Look for Part 4 in the August edition
of Endo Tribune.
ET About the author
Dr. John J. Stropko received his
DDS from Indiana University in 1964,
and he practiced restorative dentistry
for 24 years. 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 is the inventor
of the Stropko Irrigator, has published
in several journals and textbooks and
is an internationally known speaker.
He is the co-founder of Clinical Endodontic Seminars and currently on
the endodontic faculty at the Scottsdale Center for Dentistry in Scottsdale,
Ariz., as an instructor of microsurgery.
Stropko and his wife, Barbara, currently reside in Carefree, Ariz. You
may contact him at topendo@aol.com.
[7] =>
ENDO Tribune | June 2010
Industry 7B
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