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Year : 2018  |  Volume : 10  |  Issue : 1  |  Page : 1-2

Endodontic microsurgery − A technique for the 21st century

Department of Endodontics, University of Pennsylvania School of Dental Medicine, Philadelphia, PA, USA

Date of Web Publication9-Jul-2018

Correspondence Address:
Dr. Frank C Setzer
Department of Endodontics, University of Pennsylvania School of Dental Medicine, Philadelphia, PA
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jofs.jofs_48_18

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How to cite this article:
Setzer FC. Endodontic microsurgery − A technique for the 21st century . J Orofac Sci 2018;10:1-2

How to cite this URL:
Setzer FC. Endodontic microsurgery − A technique for the 21st century . J Orofac Sci [serial online] 2018 [cited 2022 Aug 7];10:1-2. Available from:

Apical or endodontic surgery has traditionally been viewed as a last resort to save a tooth, often after failed primary root canal treatment and endodontic retreatment. As a clinical technique applied by both oral surgeons and endodontists, it has not had the best reputation, largely due to great variations in techniques used over decades. For the endodontist, apical surgery is now endodontic microsurgery, the most advanced method of executing this procedure. Endodontic microsurgery, featuring the triad of high magnification, ultrasonic root-end preparation, and biocompatible root-end filling materials, was introduced in the 1990s[1] and firmly established over the past decade.[2]

The primary objective of apical surgery is to eliminate and prevent microbial leakage from the root canal system into the periradicular tissues with subsequent healing of existent apical periodontitis. Traditional techniques involved large osteotomies with either just apical resection or retrograde amalgam fillings, after cavity preparation with round burs at an acute bevel angle. This traditional approach, albeit still encountered today, has a success rate of 59%,[3] explaining negative reports for the procedure in general.

In contrast, endodontic microsurgery utilizes a surgical microscope with enhanced magnification and illumination throughout the clinical operation. This allows for atraumatic access, including more precise incision and flap elevation, as well as a smaller osteotomy compared to the traditional procedures. Hemostasis is achieved by the presurgical injection of anesthetic solutions with 1:50,000 epinephrine and intraoperatively by using epinephrine containing cotton pellets and ferric sulfate. Microinstruments are used for inspection, curettage, and root-end filling. Using the microsurgical approach, roots can be resected at a shallow bevel angle, almost perpendicular to the long axis of the tooth, sacrificing less tooth structure, and exposing less dentinal tubules. Using the microscope, the resected root surface is stained with an organic dye for inspection at high magnification (20–25×) to verify complete resection as well as anatomical details such as leaking root fillings, calcified, missed or lateral canals, isthmuses, perforations, cracks, and microfractures. Ultrasonic tips are then utilized for the preparation of a root-end cavity, again inspected and subsequently filled with a root-end filling material, including intermediate restorative material (IRM), SuperEBA, or a calcium silicate cement such as mineral trioxide aggregate (MTA). As a result of the microsurgical techniques, patients experience less trauma and faster postsurgical healing.

With proper case selection of true endodontic lesions, in contrast to combined endodontic and periodontal defects, cumulative success rates close to 94% have been achieved with this technique.[3],[4] It is of particular interest, that using loupes or the naked eye instead of the microscope will result in a significantly lower outcome of 86%, demonstrating the importance of using high magnification.[4] While there had been reports discussing the regression of periapical healing after several years of observation, these have now been shown to be associated with traditional methods or with techniques that use unconventional root-end filling techniques, relying on materials bonded to the resected root surface that are impacted by the humidity of the bony crypt. However, calcium silicate cements have been recognized to provide stable long-term results.

This detailed description of the microscopic approach should demonstrate to the reader the significant changes and advances in clinical endodontic techniques. These advances are evidence-based on basic science and clinical research and are still forthcoming. Conebeam CT (CBCT) technology has now been fully incorporated into surgical and nonsurgical endodontics for treatment planning and, with ever decreasing radiation, also for healing assessment.[5] According to a recent survey, 80% of endodontists utilize CBCT in private practices and institutional settings. In nonsurgical techniques, novel file designs facilitate better instrumentation of the true cross-sectional anatomy of root canal systems. Piezo-surgical units are utilized in endodontic surgery to prepare protective anchorage for retractors and for bone window techniques. Bioceramics, a variation of the calcium silicate cements, are replacing MTA as a root-end filling material due to better handling and also as sealers or perforation repair materials in nonsurgical treatment.

These modern, microsurgical techniques are cutting-edge, minimally invasive, and together with the renaissance of procedures such as intentional replantation, or tooth and root resection, allow for the predictable retention of natural teeth. Increased complication rates for dental implants have been recognized and it has been demonstrated that natural teeth, even if periodontally compromised or endodontically treated, have better long-term prognoses than dental implants.[6],[7] Thus, a new emphasis on the preservation of natural teeth and their use as abutments rather than their extraction and replacement has emerged.[8] The pendulum is swinging back to tooth retention, and endodontists armed with modern endodontic techniques are here to save these teeth.

  References Top

Rubinstein RA, Kim S. Short-term observation of the results of endodontic surgery with the use of a surgical operation microscope and Super-BA as root-end filling material. J Endod 1999;25:43-8.  Back to cited text no. 1
Kim S, Kratchman S. Modern endodontic surgery concepts and practice: A review. J Endod 2006;32:601-23.  Back to cited text no. 2
Setzer FC, Shah SB, Kohli MR, Karabucak B, Kim S. Outcome of endodontic surgery: A meta-analysis of the literature − Part 1: Comparison of traditional root-end surgery and endodontic microsurgery. J Endod 2010;36:1757-65.  Back to cited text no. 3
Setzer FC, Kohli MR, Shah SB, Karabucak B, Kim S. Outcome of endodontic surgery: A meta-analysis of the literature − Part 2: Comparison of endodontic microsurgical techniques with and without the use of higher magnification. J Endod 2012;38:1-10.  Back to cited text no. 4
Schloss T, Sonntag D, Kohli MR, Setzer FC. A comparison of 2- and 3-dimensional healing assessment after endodontic surgery using cone-beam computed tomographic volumes or periapical radiographs. J Endod 2017;43:1072-9.  Back to cited text no. 5
Levin L, Halperin-Sternfeld M. Tooth preservation or implant placement: A systematic review of long-term tooth and implant survival rates. J Am Dent Assoc 2013;144:1119-33.  Back to cited text no. 6
Setzer FC, Kim S. Comparison of long-term survival of implants and endodontically treated teeth. J Dent Res 2014;93:19-26.  Back to cited text no. 7
Giannobile WV, Lang NP. Are dental implants a panacea or should we better strive to save teeth? J Dent Res 2016;95:5-6.  Back to cited text no. 8


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