Endo Tribune U.S.
Apical microsurgery: the incision and atraumatic flap elevation (Part 2 of 6)
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[1] =>
ENDO TRIBUNE
The World’s Endodontic Newspaper · U.S. Edition
September 2009
www.endo-tribune.com
Vol. 4, No. 9
Apical microsurgery: the incision AAE
and atraumatic flap elevation
has new
trustees
Part 2 in a
six-part series
By John J. Stropko, DDS
Using a disposable CK2 microsurgical blade (SybronEndo), the incision
is made. With the smaller size of this
blade, very accurate incisions can be
made that have a cleaner cut than
those of the much larger BP #15 or
BP #15S blade. As the incision is being
made, the operator needs to visualize
the suturing process.
Sometimes just a small variation in
the design of the incision can make a
big difference in the ability to achieve
easier and less traumatic closure of
the surgical flap. In general, the surgeon is working with relatively healthy
tissue and no attempt should be made
to remove or alter the periodontium.
This is especially applicable when
making a full sulcular flap.
All flaps are full thickness and the
incision must be complete, so there is
no inadvertent tearing upon retraction
of the flap. The split thickness flap is
to be avoided as it is the most traumatic and healing is compromised. The
periosteum does not survive the flap
reflection procedure. It has been postulated that depolymerized periosteal
collagen plays a role in rapid reattachment of the flapped tissues to cortical
bone.1 In general, all flaps should be
extended, at a minimum, to the mesial
of the second tooth anterior to the
apex of the root being surgerized.
The flap design differs depending
on the integrity of the bone over the
roots, the amount and nature of the
attached gingival tissue, the anatomy
of the jaw and the absence or presence
of fixed dental appliances. Basically,
there are two flap designs: triangular
(one releasing incision) and rectangular (two releasing incisions). They are
normally either a full sulcular flap, or
a mucogingival flap, depending on the
location and situation. In general, the
longer the length of the flap, the easier
it is to control, and it has no effect on
the healing process.
The full sulcular flap: This design
is routinely used in all posterior quadrants. The full sulcular flap should be
used in the anterior if there is a thin
zone of attached gingival tissue or
there is a concern about the possibility of a dehiscence over the root of the
tooth being operated on.
The incision is made through the
gingival crest, following the curvature around the cervical of the teeth
involved in the surgical area. The
Fig. 1: The full sulcular flap.
operator should attempt to incise the
tissue through the crest of gingival to
the osseous crest of bone, leaving the
healthy gingival attachment intact. The
advantage of the full sulcular flap is the
ability of the operator to easily visualize
the “emergence form” of the involved
teeth.
The Leubke-Ochsenbein or Mucogingival Flap: This flap is used only
when there is an adequate amount of
attached gingival tissue present and
the periodontal probing is within normal limits. The incision design should
be scalloping in nature and generally
follows the architecture of the teeth,
which allows for easy repositioning
upon completion of the apical microsurgical procedures.
All releasing incisions are made
parallel to the long axis of the teeth.
This is important because the blood
supply to the area is also parallel to the
long axis. If a “wide base” type flap is
made, the blood supply to the tissue
adjacent to the flap is compromised
and healing may not be as predictable
and uneventful. The reflection of the
flap is accomplished using the Molt,
or Ruddle R or Ruddle L (SybronEndo)
periosteal elevators. The working end
of the instrument is gently inserted into
the releasing incision, line into the free
gingival tissue apical to the mucogingival attachment, and as far apically as
the incision and boney contours will
gently permit.
The instrument is manipulated in
a gentle apical-to-coronal movement
within the unattached gingival portion of the flap. Maintaining the same
motion, the instrument is moved slow-
ly toward the same apical position at
the more distal extent of the flap. The
working end of the elevator should be
sharp so the reflection will be a “dissecting” process, so crushing or tearing
of the tissue is avoided. Occasionally,
especially in the posterior quadrants
of the mandible, the mucogingival
line will clinically seem to be firmly
attached to a microscopic boney ridge.
The attached tissue must be gently
dissected from it. Once the mesial few
millimeters are elevated, the rest will
generally “peel away” without much
effort at all and easily release from the
g ET page 2C
A. Eddy Skidmore, DDS, MS,
was named president of the American Association of Endodontists
Foundation Board of Trustees for
the 2009-2010 year at the AAE’s
recent annual session in Orlando.
Additionally, three new AAE
members were nominated and
three public-sector trustees were
renominated.
Skidmore, a former professor,
chairman and program director at
West Virginia University School of
Dentistry, joined the AAE in 1969.
The foundation’s other 20092010 appointments include:
• Kevin M. Keating, DDS, MS,
an associate clinical professor in
endodontics at the University of
California at San Francisco.
• Peter A. Morgan, DMD,
M.Sc.D., a former associate clinical
professor at the Goldman School of
Dental Medicine.
• Bill Newell, vice president and
general manager of DENTSPLY
Tulsa Dental Specialties.
• Mary Pettiette, DDS, MS, a
part-time professor at the UNC
School of Dentistry and a former
member of AAE Board of Directors.
• GorgAnna Randolph, who
served as AAE Foundation Board
secretary in 2008-2009, is a cofounder of ProBusiness Systems.
• Michael Stone, who served
as a trustee of the 2008-2009 AAE
Foundation’s Board of Directors,
is president of New York-based
Schick Technologies.
AD
[2] =>
2C
Clinical
Endo Tribune | September 2009
f ET page 1C
osseous surface. The time spent initially, to gently free the attached gingiva,
will be rewarded by a more uneventful healing process. This atraumatic
elevation and reflection of the flap is a
major contributor to the rapid healing
response routinely observed only 24
hours postoperatively. It is important
the approximating surfaces of the flap
are never touched after the incision is
completed, so there are no crushing
injuries to inhibit or retard the healing
process. An instrument such as the old
wax spatula-shaped periosteal elevator has no place in the armamentarium of the endodontic micro surgeon.
Once the flap is gently and cleanly
reflected, any “tissue tags” should be
left intact as they will aid in the healing
process. It is not necessary to clean the
flap and exposed bone because these
Fig. 2:
The
incision
ideally
preserves
the healthy
periodontal attachment.
efforts are time consuming, could be
traumatic to both the hard and soft
tissue, and ultimately compromise the
healing process.
The retraction of the flap must also
be accomplished in a gentle and atraumatic manner. The most common
cause of postoperative pain and swelling arises from impingement of the
tissue during the retraction process.
The surgeon has to constantly monitor
the end of the retractor to make sure
there is no inadvertent impingement
on the flap. This is when the “scope
assistant” is most helpful because he or
she is observing the surgical site with a
different set of eyes! An effective way
to achieve atraumatic retraction is to
prepare a groove in the cortical plate of
the bone, well apical to the anticipated
access to the root-end.
A surgical length #8 round bur, on a
high speed Innovator handpiece (SybronEndo), is used to make the groove.
A high-speed handpiece that has air
escaping from the working end should
never be used because of the danger of
air embolism. The “groove” creates a
definite place for the retractor instrument to seat into and is easily maing ET page 3C
AD
ENDO TRIBUNE
The World’s Endodontic Newspaper · U.S. Edition
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Torsten R. Oemus
t.oemus@dental-tribune.com
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e.seid@dental-tribune.com
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Robin Goodman
r.goodman@dental-tribune.com
Editor in Chief Endo Tribune
Frederic Barnett, DMD
BarnettF@einstein.edu
International Editor Endo Tribune
Prof. Dr. Arnaldo Castellucci
Managing Editor/Designer
Implant & Endo Tribunes
Sierra Rendon
s.rendon@dental-tribune.com
Managing Editor/Designer
Ortho Tribune & Show Dailies
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k.colker@dental-tribune.com
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Dental Tribune America, LLC
213 West 35th Street, Suite #801
New York, NY 10001
Tel.: (212) 244-7181
Fax: (212) 244-7185
Published by Dental Tribune America
© 2009, Dental Tribune America, LLC.
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.
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Tell us
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you
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Do you have general comments or criticism you
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would like to see more articles about? Let us know
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ET
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.
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] =>
Clinical 3C
ENDO Tribune | September 2009
ET About the author
f ET page 2C
tained in position, by either the doctor
or the assistant, and eliminates the
problem of inadvertently slipping during the surgery. Impingement of the
tissue is also more predictably avoided
by using a groove to hold the retractor.
Retraction can be accomplished
using either the Carr or Rubinstein
Retractors; however, there are many
styles of retractors to choose from. The
retractor is chosen that will best maintain clear visibility to the surgical area
and is comfortable for the operator.
After the flap is retracted and if there
is any tension on the flap, the vertical
releasing incision can be extended,
or an additional “releasing incision”
at the opposite side of the flap can be
considered. The releasing incision is
usually very minimal, only 3–4 mm
long, and many times does not require
suturing.
It is imperative the operator keeps
in mind there should be no tension or
stretching of the tissues. One should
not hesitate to extend or modify the
incision to eliminate tension on the
tissues. When there is tension, there is
usually an opportunity for crushing or
ischemia of the tissue and a resultant
delay in the healing process. Generally
speaking, the larger the flap, the easier
it is to maintain atraumatically during
the surgical procedure.
It is important the tissues and osseous surface must be kept as moist as
possible during the entire procedure.
This can be accomplished with a fine
Fig. 3: The Leubke-Ochsenbein Flap,
or Mucogingival Flap, is used when
cosmetics are a concern and there is
an adequate zone of attached gingiva.
Fig. 4: The Molt, or Ruddle elevators, are inserted into the vertical
releasing incision to begin the atraumatic flap elevation.
Fig. 5: The most common cause of
postoperative pain is tissue impingement by the retractor.
Fig. 6: Rubenstein retractor placed
into the prepared groove.
stream of water from the Stropko irrigator (www.stropko.com).
Dr. Berman, an old retired general surgeon and one of my dental
school instructors, would begin each
surgery by saying, “Treat the tissues
with tender loving kindness and they
will respond in a like manner.” How
many times I have heard those very
words while performing apical microsurgery. Apical microsurgery can truly
be a gentle technique. ET
In the next issue: Apical microsurgery, Part 3: access and crypt management.
John J. Stropko received his DDS from
Indiana University in 1964, and for 24
years, he practiced restorative dentistry.
In 1989, he received his 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, an adjunct
assistant professor at Boston University,
an assistant professor of graduate clinical
endodontics at Loma Linda University
and on the endodontic faculty at the Scottsdale Center for Dentistry in Scottsdale,
Ariz. Stropko has performed numerous
live micro-endodontic and micro-surgical
demonstrations nationally and internationally. He is the inventor of the Stropko
Irrigator and the co-founder of Clinical Endodontic Seminars. Stropko and
his wife, Barbara, currently reside in
Carefree, Ariz. You may contact him at
topendo@aol.com.
References available upon request.
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[4] =>
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Folio
Endo Tribune | Month 2009
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