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MicrosurgeryinEndodontics Microsurgery in Endodontics SyngcukKim,DDS,PhD,MD(Hon) SamuelKratchman,DMD AssociateEditors: BekirKarabucak,DMD,MS MeetuKohli,DMD FrankSetzer,DMD,MS,PhD Thiseditionfirstpublished2018 ©2018JohnWiley&Sons,Inc. Allrightsreserved.Nopartofthispublicationmaybereproduced,storedinaretrievalsystem,ortransmitted,inanyformorbyany means,electronic,mechanical,photocopying,recordingorotherwise,exceptaspermittedbylaw.Adviceonhowtoobtainpermissionto reusematerialfromthistitleisavailableathttp://www.wiley.com/go/permissions. TherightofSyngcukKimandSamuelKratchmantobeidentifiedastheauthorsoftheeditorialmaterialinthisworkhasbeenassertedin accordancewithlaw. RegisteredOffice JohnWiley&Sons,Inc.,111RiverStreet,Hoboken,NJ07030,USA EditorialOffice 111RiverStreet,Hoboken,NJ07030,USA Fordetailsofourglobaleditorialoffices,customerservices,andmoreinformationaboutWileyproductsvisitusatwww.wiley.com. 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Neitherthepublishernorauthorsshallbeliableforanylossofprofitoranyothercommercialdamages,includingbutnotlimitedtospecial, incidental,consequential,orotherdamages. LibraryofCongressCataloging-in-PublicationData Names:Kim,Syngcuk,editor.|Kratchman,Samuel,editor.|Karabucak,Bekir,editor.|Kohli,Meetu,editor.|Setzer,Frank,editor. Title:Microsurgeryinendodontics/editedbySyngcukKim,SamuelKratchman;associateeditors,BekirKarabucak,MeetuKohli,Frank Setzer. Description:Hoboken,NJ:Wiley,2018.|Includesbibliographicalreferencesandindex.| Identifiers:LCCN2017026730(print)|LCCN2017028087(ebook)|ISBN9781119403654(pdf)|ISBN9781119403661(epub)| ISBN9781118452998(cloth) Subjects:|MESH:DentalPulpDiseases–surgery|Microsurgery–methods|Endodontics–methods Classification:LCCRK351(ebook)|LCCRK351(print)|NLMWU230|DDC617.6/342–dc23 LCrecordavailableathttps://lccn.loc.gov/2017026730 CoverImages:(Mainandtopinsetimages)CourtesyofDrs.SyngcukKimandSamuelKratchman;(Leftinsetimage)Courtesyof Dr.KanameYokota;(Rightinsetimage)CourtesyofDr.GarrettGuess CoverdesignbyWiley Setin10/12ptWarnockProbyAptaraInc.,NewDelhi,India 10 9 8 7 6 5 4 3 2 1 This book is dedicated to our “PENN ENDO FAMILY”; those who were educated at Penn. Without their dedication and practice in their schools and offices this field would not be what it is today! vii Contents Contributors xiii Preface xv Acknowledgements xvii  TheDentalOperatingMicroscope 1 FrankSetzer 1.1 BenefitsoftheOperatingMicroscope 1 1.2 KeyFeaturesofOperatingMicroscopes 1 1.3 CustomizingaMicroscope 3 1.3.1 LightSource 3 1.3.2 Documentation 5 1.3.3 IndividualMicroscopeAdjustment(Parfocaling) 5 SuggestedReadings 7  MicrosurgicalInstruments 9 SeungHoBaekandSyngcukKim 2.1 ExaminationInstruments 9 2.2 IncisionandElevationInstrument 9 2.3 TissueRetractionInstruments 11 2.4 OsteotomyInstruments 14 2.5 CurettageInstruments 14 2.6 InspectionInstruments 15 2.7 UltrasonicUnitsandTipsforRootEndPreparation 17 2.8 MicropluggerInstruments 20 2.9 SuturingInstruments 20 2.10 MiscellaneousInstruments 22  Medication-RelatedOsteonecrosisoftheJawandEndodonticMicrosurgery 25 ChaficSafiandBekirKarabucak SuggestedReadings 29  IndicationsandContraindications 31 BekirKarabucakandGarrettGuess 4.1 Introduction 31 4.2 SurgicalSuccessDependentonAbilitytoPerformIdealProtocols 31 4.3 EtiologyAssessmentthroughExaminationandTreatment 31 4.4 PeriodontalConsiderationsandSurgery 33 4.5 InfluentialPatientFactors 33 4.6 ConditionofPreviousEndodonticTreatment 37 SuggestedReadings 38 viii Contents  AnesthesiaandHemostasis 39 SivaRethnam-Haug,AleksanderIofin,andSyngcukKim 5.1 Armamentarium 39 5.1.1 Epinephrine 39 5.2 PresurgicalPhase 40 5.2.1 AdministrationofLocalAnesthetic 40 5.2.2 InjectionTechniques 40 5.2.3 TopicalAnesthesia 41 5.2.4 AdditionalTechniques 41 5.2.5 MaxillaryAnesthesia 41 5.2.6 MandibularAnesthesia 43 5.2.7 BilateralMandibularSurgery 43 5.3 SurgicalPhase 44 5.3.1 TopicalHemostaticAgents 44 5.3.1.1 EpinephrinePellets 45 5.3.1.2 FerricSulfate 45 5.4 SummaryofHemostaticTechniquesinEndodonticMicrosurgery 46 5.5 PostsurgicalPhase 46 SuggestedReadings 48  FlapDesigninEndodonticMicrosurgery 49 FrancescoMaggioreandFrankSetzer 6.1 Armamentarium 49 6.1.1 FlapOutline 49 6.1.2 PapillaManagement 52 6.1.3 Incision 54 6.1.4 FlapElevation 54 6.1.5 FlapRetraction 55 SuggestedReadings 56  Osteotomy 57 FrancescoMaggioreandSyngcukKim 7.1 Armamentarium 57 7.2 Osteotomy 57 7.2.1 DistinctionbetweenBoneandRootTip 57 7.2.2 ClinicalSituationsforEndodonticMicrosurgery 58 7.3 IntactCorticalPlatewithoutaRadiographicPeriapicalLesion 59 7.4 IntactCorticalPlatewithaPeriapicalLesion 60 7.5 FenestrationthroughtheCorticalPlateLeadingtotheApex 60 7.5.1 OptimalOsteotomySize 61 7.5.2 KeyHoleOsteotomyModification 61 7.5.3 BoneWindowTechnique 61  RootEndResection 67 SpyrosFloratos,FouadAl-Malki,andSyngcukKim 8.1 Armamentarium 67 8.2 RootEndResection 67 8.3 RootEndResection:SteepBevelversusShallowBevel 69 SuggestedReadings 72  InspectionoftheResectedRootSurface:ImportanceofIsthmus 73 SpyrosFloratos,JorgeVera,FouadAl-Malki,andSyngcukKim 9.1 Armamentarium 73 9.1.1 MethyleneBlueStaining(MBS) 73 Contents ix 9.1.2 Isthmus 77 9.1.3 TypesofIsthmus 77 9.1.4 Incidence 77 9.1.5 HistologicalFindingsofIsthmus 79 9.1.6 ClinicalSignificanceandManagement 81 SuggestedReadings 82  UltrasonicRootEndPreparation 83 SpyrosFloratosandSyngcukKim 10.1 Armamentarium 83 SuggestedReadings 89  MTAandBioceramicRootEndFillingMaterials 91 SujungShin,IanChen,BekirKarabucak,SeungHoBaek,andSyngcukKim 11.1 MineralTrioxideAggregate(MTA) 92 11.1.1 AdvantagesofMTA 92 11.1.1.1 SealingAbility 92 11.1.1.2 BiocompatibilityandBioactivity 92 11.1.2 DrawbacksofMTA 93 11.2 Bioceramics 93 11.3 MTAandBioceramicApplicationDuringApicoectomy 95 11.4 OtherTypesofCementsforRootEndFilling 96 11.4.1 IntermediateRestorativeMaterial(IRM) 97 11.4.2 SuperEthoxybenzoicAcid(SuperEBA) 97 11.4.3 GeristoreandRetroplast 98 11.4.4 NewTypesofCementsforRootEndFilling 98 SuggestedReadings 98  FlapRepositionandSuturing 101 FrancescoMaggioreandMeetuKohli 12.1 SutureRemoval 101 SuggestedReadings 111  PeriapicalWoundHealing 113 IngridaDapkute,GeorgesBandelac,ChaficSafi,andFrankSetzer 13.1 PrinciplesofWoundHealing 113 13.2 HealingafterApicalMicrosurgery 113 13.3 IncompleteHealing/ScarFormation 113 13.4 EvaluationofHealingafterApicalSurgery 114 13.5 HealingEvaluationUsingCBCT 115 SuggestedReadings 118  ConeBeamComputedTomography 119 GarrettGuess,FouadAl-Malki,MeetuKohli,BekirKarabucak,andSamuelKratchman 14.1 HowCBCTWorks 120 14.2 IndicationsandClinicalApplications 120 SuggestedReadings 142  MentalNerveManagement 143 PaulaMendez-Montalvo,FouadAl-Malki,andSyngcukKim 15.1 Armamentarium 143 15.1.1 MentalForamenandNerve 143 15.1.1.1 Location 143 15.1.1.2 AnteriorLoop 143 x Contents 15.1.1.3 NumberofMentalForamina 144 15.1.2 MentalForamenDetectiononRadiographs 144 15.1.2.1 PeriapicalRadiograph 144 15.1.2.2 PanoramicFilms 145 15.1.2.3 ConeBeamComputedTomography(CBCT) 145 15.1.3 NeurosensoryAlteration 145 15.1.3.1 SurgicalTechniquetoAvoidIatrogenicMentalNerveTraumaandInjury 146 15.1.4 GrooveTechniqueUsingPiezoelectricSurgery 146 SuggestedReadings 150  MaxillaryPosteriorSurgery,theSinus,andManagingPalatalAccess 151 GarrettGuessandSamuelKratchman 16.1 MaxillaryPremolars 151 16.1.1 Access 151 16.1.2 Instrumentation 151 16.2 SinusExposure 151 16.3 MaxillaryFirstMolars 153 16.3.1 Access 153 16.3.2 PalatalApproach 155 16.4 SecondMolars 159 16.4.1 PeriodontalAspects 161 SuggestedReadings 162  SurgicalRootPerforationRepair 163 RaedKasem,SamuelKratchman,andMeetuKohli 17.1 PossibleChallengestoNon-surgicalPerforationRepair 163 17.2 FactorsthatEnhancePositiveLong-TermPrognosisforPerforationRepair 164 17.3 SurgicalPerforationRepairTechniques 166 17.4 SurgicalTreatmentforExternalRootResorption 168 SuggestedReadings 177  IntentionalReplantation 179 DavidLiandSamuelKratchman 18.1 Armamentarium 179 18.1.1 SuccessRate 179 18.1.2 Indications 179 18.1.3 ReplantationorApicoectomy 179 18.1.4 Extraction 182 18.1.5 ExtraoralPhase 183 18.1.6 StorageMedium 183 18.1.7 Replantation 183 18.1.8 Splinting 185 18.1.9 PostopInstructions 186 18.1.10 ConeBeamCTScan 186 18.1.11 RepairingProceduralMishaps 186 SuggestedReadings 191  GuidedTissueRegenerationinEndodonticMicrosurgery 193 GarrettGuessandSamuelKratchman SuggestedReadings 202  ImplantsversusEndodonticMicrosurgery 205 FrankSetzerandSyngcukKim 20.1 HistoricalPerspective 205 20.2 BenefitsofImplants 205 Contents xi 20.3 Long-TermPrognosisofDentalImplants 205 20.4 ImplantComplications 206 20.5 Long-TermPrognosisofEndodonticallyTreatedTeethwithRootEndSurgery 207 20.6 Conclusion 209 SuggestedReadings 210  PrognosisofEndodonticMicrosurgery 213 MeetuKohliandEuiseongKim 21.1 BestAvailableEvidence 213 21.2 ParametersforSuccess:ClinicalandRadiographic2D 214 21.3 ParametersforSuccess:“Penn3DCriteria”forAssessingHealingonCBCT 215 21.4 ReversalofSuccess 215 21.5 TraditionalMethods 217 21.6 ModernTechniqueversustheCompleteMicrosurgicalApproach 218 21.7 RootEndFillingMaterials 218 21.8 CaseSelection 219 21.9 Resurgery 219 21.10 Summary 219 SuggestedReadings 219  Positioning 221 SamuelKratchmanandSyngcukKim 22.1 Armamentarium 221 SuggestedReadings 226 Index 227 xiii Contributors FouadAl-Maki,DDS AleksanderIoﬁn,DMD EndodonticResident ClinicalAssistantProfessorofEndodontics DepartmentofEndodontics DepartmentofEndodontics SchoolofDentalMedicine CollegeofDentalMedicine UniversityofPennsylvania ColumbiaUniversity Philadelphia,PA,USA AdjunctClinicalAssistantProfessorofEndodontics DepartmentofEndodontics SeungHoBaek,DDS,MSD,PhD SchoolofDentalMedicine Professor/ChairmanEmeritus UniversityofPennsylvania DepartmentofConservativeDentistry Philadelphia,PA,USA SchoolofDentistry PrivatePractice:NewYork,NY SeoulNationalUniversity,SouthKorea BekirKarabucak,DMD,MS GeorgesBandelac,DDS,MS ChairandAssociateProfessorofEndodontics DiplomatAmericanBoardPeriodontology Director,PostdoctoralEndodonticsProgram DepartmentofEndodontics IanChen,DDS,MS SchoolofDentalMedicine LecturerSchoolofDentistry UniversityofPennsylvania NationalYang-MingUniversity Philadelphia,PA,USA AdjunctClinicalInstructor DepartmentofDentistry RaedKasem,DDS,MS NationalTaiwanUniversityHospital AdjunctAssistantProfessor PrivatePractice:Taipei,Taiwan DepartmentofEndodontics SchoolofDentalMedicine IngridaDapkute,DMD,MS UniversityofPennsylvania PrivatePractice:Landsdale,PA Philadelphia,PA,USA PrivatePractice:Clearwater,Trinity,Tampa,FL SpyrosFloratos,DMD AdjunctAssistantProfessor EuiseongKim,DDS,MSD,PhD DepartmentofEndodontics ProfessorandChairman SchoolofDentalMedicine ViceDeanforGraduateAffairs UniversityofPennsylvania Director,OralScienceResearchInstitute Philadelphia,PA,USA DepartmentofConservativeDentistry PrivatePractice:Athens,Greece CollegeofDentistry YonseiUniversity,Korea GarrettGuess,DDS AdjunctAssistantProfessor SyngcukKim,DDS,PhD,MD(Hon) DepartmentofEndodontics LouisI.GrossmanProfessorandChairman SchoolofDentalMedicine DepartmentofEndodontics UniversityofPennsylvania AssociateDeanofGlobalAffairs Philadelphia,PA,USA AssociateDeanforAdvancedDentalEducation DiplomateAmericanBoardofEndodontics SchoolofDentalMedicine PrivatePractice:SanDiego,California UniversityofPennsylvania Philadelphia,PA,USA