History of Endodontics aae/abe

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Causes of Persistent AP

Nair 2006

  1. Intraradicular Infection

  1. Extraradicular Infection

  1. Foreign Body Rxn

  1. Apical Cyst (True cyst)

  1. Cholesterol Crystals

  1. Apical Scar

Persistent AP & Extraradicular Infection

Extraradicular Infection Rare (outside of AAA/CAA):

  1. Sjogren, Sundqvist et al 1988 IEJPropionibacterium propionicum may be implicated in Extraradicular infection

  2. Nair 1984 JOEActinomyces israelii is able to establish Extraradicular infection

  3. Ricucci/Siqueira 2010– 106 roots w/ AP (42 previously treated) Intraradicular biofilms present: Cysts 95%, Abscesses 83%, Granulomas 70%; Extraradicular biofilms 6%. No correlation between biofilm presence and clinical symptoms or sinus tracts; Intraradicular biofilms are responsible for the AP (CAGE)

Extraradicular Infection Common: See also Tronstad/Barnett (biofilms)

  1. Sunde/Tronstad JOE 2002- Microbiota of Periapical lesions refractory to endodontic therapy: AAP or CAA cases – Sampling of Periapical lesion during surgery. 35/36 positive for extraradicular infection. 51% Anaerobes, 79% Gram +, 148 microbial strains, Avg. 4.1 strains/case


  1. Van Nieuwenhuysen 1994Radiographic monitoring (6 years) of asymptomatic previously treated teeth (n=420) with radiographically deficient filling and no/small PA lesions: Stable: 94.8%, Healing: 2.4%, Failure: 2.8%

  1. Gorni/Gagliani 2004 – 451 patients, 2 year recall, Friedman healing categories (Healed, Diseased), Healed + Healing = Success

    1. Root Canal Morphology Respected (RCMR)calcifications, apical stop, broken instruments, short fill

    2. Root Canal Morphology Altered (RCMA) – transportation, perforation, stripping, internal resorption

Findings: Overall success: 69%, RCMR: 87%, RCMA: 47%

  1. Hoen/Pink 2002 – 337 Retx teeth, 89% of teeth with asymmetric obturation had additional canal located during Retx

How do silver points cause a problem?

Seltzer et al

  1. Silver wires removed from failed endodontic cases showed corrosion products of silver sulfate products which are cytotoxic

  1. Leakage from around the round wire within a non-round canal causes washout of the cement and fluid contact with the silver wire

  1. Oxidation of the wire leads to the corrosive byproducts – silver sulfate

Leakage  oxidation  corrosion/byproducts (silver sulfate)  cytotoxic

What are some techniques to remove separated instruments or silver points?

  1. Hulsmann 1993 EDT – Recommends using the needle sleeve tech, endo extractor, braiding Hedstrom files, Masserann kit, ultrasonics, Gonon post remover

  1. Krell 1984 JOE – Recommends ultrasonic application and Hedstrom files for silver points

  1. Ruddle JOE 2004Staging platform w modified gg; ultrasonics; never around curve; if unable w/ ultrasonics, try IRS system, tube/glue system, or bypass w/files

  1. Nevares JOE 2012 – Success of instrument removal/bypass: Fragment visualized: 85%, Fragment not visualized: 48%

  1. IqbalStaging platform most centered with lightspeed when prepared in the apical 1/3rd

How do you remove posts?

  1. Berbert IEJ 1995 - Reduced forces were necessary to remove the posts that were treated with an Ultrasonic device compared with posts which did not receive ultrasonic treatment.

  1. Baumgartner JOE 1997 – Takes longer to remove post with ultrasonic forces than with the Gonan system. Ultrasonic system induces more cracks than the Gonan system (but NSD)

  1. Ruddle JOE 2004 – Review – Evaluate the curvature and circumferential diameter of root and post type (parallel vs tapered, active vs non-active, metallic vs. non-metallic) in determining ability to remove post. Post removal with ultrasonics and Ruddle Post Removal System (trephine/tap/extractor pliers)

  1. Dominici/Eleazer – High root temps with ultrasonic > 15 s --- use water coolant

Is Chloroform safe for retreatments ?

  1. McDonald 1992 JOE – In vivo, Chloroform is safe for the dentist/staff. Air vapor levels were well below OSHA mandated levels (2 ppm/8 hrs).

  1. Chutich 1998 JOE – In vitro, No health risk to the patient, amount of chloroform expelled thru the apex (0.32mg) is several orders of magnitude below the permissible toxic dose (49mg)

  1. Rotstein 1999 OOO – chloroform may cause a significant softening effect on both enamel and dentin. This softening is already apparent after 5 minutes of treatment.

Is Chloroform antimicrobial?

  1. Edgar/Baumgartner60% reduction in E. faecalis using Chloroform in Retx (11/17 neg cultures Chloroform, 0/17 neg cultures Saline)

Are other means available to remove gutta-percha?

Can it be removed completely?

  1. Kaplowitz 1990 JOE – tested 5 solvents (halothane, xylene) but found chloroform was the only one that completely dissolved the gutta-percha

  1. Schafer 1987 OOO – tested chloroform vs eucalyptus oil, chloroform was far more effective.

  1. Krell 1987 JOE – Evaluated 4 methods to remove root canal filling, AH26 was more difficult to remove than Roth’s. All methods left some debris on the canal walls.

  1. Wilcox 1991 JOE – Retreating ones own failures is unlikely to debride areas previously undebrided because reinstrumentation usually enlarges in the same directions as the first instrumentation.

Are other means available to remove gutta-percha?

Can it be removed completely?

  1. Hansen 1998 JOE – tested several solvents to remove different sealers. Only chloroform removed AH-26 (epoxy resin sealer)

  1. Metzger 1995 JOE – presented procedure for removal of overextended root canal filling – extend file 0.5-1.0 mm beyond apex/engage gp

  1. Saad/Al-Hadlaq 2007 JOECompared K3 & ProTaper NiTi files to Hedstrom hand files for gp removal in retx procedure

    1. All techniques left some gp/sealer remaining

    2. K3 & PT removed significantly more gp/sealer than Hedstroms

    3. K3 & PT instrumentation took significantly less time

    4. No difference in apical extrusion among all groups

How do you remove Thermafil ?

Tulsa recommends: work down around carrier with small files and solvent until it is free. If Thermafil Plus was used, a rotary file can be used to engage the vent in the carrier. Ultrasonics may also be useful. Thermafil Plus has a groove in the core to vent GP during placement and to ease retreatment.

  1. Bertrand 1997 JOE – Use chloroform and hand files (k-files, hedstroms) to remove Thermfil carriers

  1. Baratto 2002 IEJ – 0.04 Pro Files were used to remove Thermafil plastic carriers at 300 rpm in a crown down manner. Unable to remove all gutta-percha from canals

  1. Wolcott/Hicks 1999 JOE – Tested the application of a System B at 225 degrees C (carrier melts at 300). Recommend heat and insert system B tip 10-15mm for 5-8 sec, then k-files (#30-50) on either side of the carrier with apical pressure and counter clockwise rotation.

What is Resorcinol-formaldehyde resin “Russian Red”?

  1. Schwandt 2003 JOE – A material used is many foreign countries. Contains two toxic components, resorcinol and formaldehyde. Forms brick hard red material that has no solvent. Requires no instrumentation, presumably “fixes” tissue and kills bacteria apical to paste level.

  1. Vranas/Hartwell 2003 JOE – This study tested the effectivness of 0.9% NaCl, 5.25% NaOCl, chloroform, or Endosolv R on softening Resorcinol disks. Evaluated depth of probe penetration. NaOCl was superior to all other groups after 5 minutes. No solvent clinically effective.

  1. Gambrel/Hartwell 2005 JOE – In vitro – resorcinol/formalin paste fills and extracted teeth – no solvent (same as above) clinically effective at softening paste. EndoSolv R was stat. superior for probe penetration but this did not translate into a clinical effect.


Anatomical considerations during periapical surgery


  1. Eberhardt/Torabinejad 1992 OOO – Distance of Apices of Maxillary posterior teeth and floor of maxillary sinus measured (CT scan): MB root of Max 2nd molar is closest to the sinus (1.97mm avg) but farthest from the buccal bony surface (4.45mm avg). Max 1st bicuspid is closest to the B plate (1.63mm avg) but farthest from the floor of the sinus (7.05mm). 5% of apicies protrude into the sinus.

  1. Lin & Langeland 1985 JOE – Recommend the use of nasal decongestant in the event of a sinus perforation (0.5% neosynephrine). Add antibiotics only if acute sinusitis develops, do not give prophylactically.

  1. Rud 1998 JOE – Sinus perforations occur in half of all cases studied. Results of this study support the use of antibiotics based on case need, NOT prophylactically.

Anatomical considerations during periapical surgery


  1. Waztek/Bernhart DCNA 1997Sinus perforations occurred in 28% of maxillary posterior endodontic surgeries. No difference in healing.

  1. Kretzschmar – Give 10 day course of Nasal Decongestants/Oral Antihistamines (Neosynephrine/Pseudophedrine) and Amox 500 mg q6h for iatrogenic sinus exposure (opposes Lin/Langeland for antibiotic coverage)

  1. Mailet/McClanahan – ~50% of cases of Maxillary sinusitis identified on CBCT were odontogenic in origin. Avg. mucosal thickening = 7.4 mm. Maxillary 1st and 2nd molars were 11x more likely involved than Maxillary 1st or 2nd Premolars. P root of Maxillary 1st Molars and MB root of Maxillary 2nd Molars were most likely associated with Maxillary sinusitis.

Mental Foramen

  1. Moiseiwitsch 1995 JOE – This study described 3 steps to minimize risk of damage to the neurovascular bundle exiting the mental foramen

    1. Take vertical periapical film

    2. Use triangular flap with the vertical releasing incision distal

    3. Make a groove in the bone superior to the foramen to prevent retractor slippage

  1. Phillips 1990 JOE – Most common location of the mental foramen:

    1. Inferior to the mandibular second bicuspid

    2. 60% of the distance from the buccal cusp tip to the inferior border of the mandible.

    3. It exits in a posterior and superior direction

Mandibular Canal

  1. Denio/Torabinejad 1992 JOE – Anatomic relationship of Mandibular canal to Posterior teeth apices – 2nd Molar/2nd Premolar most problematic:

Distance from Root apex to Canal:

2nd Molar: 3.7 mm

1st Molar: 6.9 mm (~7.0 mm)

2nd Premolar: 4.7 mm

Canal Path:

S-shaped: 31% - Buccal to the distal root 2nd Molar, crosses to lingual below mesial root 2nd Molar, runs lingual to 1st Molar, then crosses to buccal below apex of 2nd Premolar

Lingual: 19%, Buccal: 17%, Directly below: 5%

  1. Koivisto 2011 JOECBCT analysis of proximity to mandibular canal. Mandibular 2nd Molars closest to IAN. Mesial roots of Mandibular 2nd Molars closest to IAN in Females and young pts (< 18 y.o.).

Discuss Flap Design for Surgery

  1. Kramper/Kaminski 1984 JOE – Dog study

    1. Submarginal incision is the flap of choice when not contraindicated by anatomical location of the lesion (Incision should be placed over bone) or by insufficient attached gingiva (Attached gingiva must be 3 mm wide between base of sulcus and incision)

    2. Intrasulcular: Greater Inflammation, bone loss and recession

    3. Semilunar: Greater Inflammation

  1. Velvart 2002 IEJPapilla based incision – allows rapid and predictable recession-free healing following surgical exposure of the soft tissues. Soft tissue management in surgery.

  1. Kim/Kratchman – Recommends Intrasulcular or Submarginal (mucogingival) flap design; Also discusses Velvart’s papillary based incision

Discuss root end resection. How far should you resect? Bevel?

  1. Pathways of the Pulp 8th edition - When 3mm of the apex is resected 93% of lateral canals are removed. Additional resection reduced the percentage insignificantly as per Vertucci. A root resection of 3mm at a 0 degree bevel angle removes the majority of anatomic entities that are potential causes for failure.

  1. Weller/Kim 1995 JOE – 50 Maxillary Molars MB root - Incidence of Isthmus: Highest in the Apical 3-5mm levels (80-100%). In teeth with two MB canals the 4mm section contained a complete or partial isthmus 100% of the time. Failure to treat the isthmus may be responsible for endodontic failures.

  1. Von Arx 2005 IEJMandibular Molars – Frequency of Isthmus: M root – 83%, D root – 36%

Discuss root end resection. How far should you resect? Bevel?

  1. Kim/Kratchman3 mm resection – eliminates 98% apical ramifications and 93% lateral canals (AR/LCs)

  1. Tidmarsh/Arrowsmith 1989SEM analysis of resected root ends, due to dentinal tubule communication, angle of bevel should be minimal and retroprep extend at least to coronal end of bevel

  1. Gilheany/Figdor 1994 JOEDye leakage study of depths/angles (0, 30, 45) for retroprep/fill - Apical leakage may be reduced by resecting at a 0 bevel and increasing the depth of the retrograde filling . Recommends retroprep depth to extend coronal to pulpal termination of dentinal tubules (1.0 mm for 0 bevel)

  1. Tetsch – Round bur best for removing osseous tissue

Discuss root end resection. How far should you resect? Bevel?

  1. Morgan/Marshall – Multipurpose bur best for Root Resection

  1. Gagliani 1998 JOE – An apical preparation of 3mm or more along the vertical axis can produce a safe and effective seal. The bevel should not be greater than the depth of the retropreparation: 1mm for 0 bevel, 2.5 mm for 45 bevel

  1. Christiansen IEJ 2009Randomized Clincal Trial: 44 patients: 2 groups: 1) 3 mm Retroprep/MTA retrofill, 2) Burnished GP w/No retroprep/fill. Healing (1 yr follow up): MTA (1): 96%, GP (2): 52%. Significance of Retroprep/Fill vs. No Retroprep/Fill.

Compare ultrasonic and bur root end preparation

NOTE – Richman was 1st to propose use of ultrasonics (root canal debridement and apicoectomy). Carr popularized it.

  1. Carr 1997 DCNA – Ultrasonic technique satisfies all the major requirements for ideal retropreparations: a class 1 preparation at least 3mm into dentin with walls parallel to and coincident with the anatomic outline of the pulpal space.

  1. Engel 1995 JOE – This study suggests that the ultrasonic handpiece offers better control, preps were more centered on the canal and isthmus, and there was less gouging of the canal walls when compared to the microhandpiece.

  1. Melhaff/Baumgartner 1997 JOE – Ultrasonic preps were deeper, deviated less from the canal, required less bevel and smaller bony crypts

Does the ultrasonic tip cause cracks in the root end?


  1. Saunders 1994 IEJ – No difference in the dye leakage studies until 7 months and then both leaked equally. Cracking was detected most often with the ultrasonically prepared roots

  1. Belini/Morgan/Marshall/Baumgartner 1999 JOE – In vivo study that found no cracks after the root resection but one incomplete crack after the ultrasonic root-end preparation.

  1. Abedi/Torabinejad 1995 OOOSEM/photomicrograph comparison of ultrasonics vs. burs for root end resection and crack formation. Higher incidence of crack formation with Ultrasonics: Crack formation is a function of time, power and dentin thickness.

Does the ultrasonic tip cause cracks in the root end?


  1. Brent/Morgan/Marshall/Baumgartner 1999 JOESS Ultrasonics – cracks noted, Diamond coated Ultrasonics – no additional cracks, eliminated several cracks, but left heavily abraded, debris-coated cavosurface that may affect the apical seal. Root-end cracks NOT seen w/diamond US.

  1. Bakland 1996 EDT – Use medium setting with water spray on ultrasonic for root-end preps to minimize infractions.

  1. Peters 2001 IEJNo difference between stainless and diamond coated ultrasonic tips regarding microcracks of root ends. Diamond tips were faster, only one microcrack was seen; incidence is low.

Discuss hemostasis during surgery

  1. Gutmann IEJ 1996 – 4 actions of hemostasis with collagen:

    1. Stimulation of platelet adhesion, aggregation, release

    2. Activation of factor XIII (Hagamen) and other clotting factors

    3. Mechanical tamponade

    4. Release of Serotonin (5-HT)

  1. Kim/KratchmanEndodontic Microsurgery Review DCNA 1997:

    1. Bone wax

Aurelio Acts mechanically via tamponade effect, foreign body reaction may occur if left in surgical site. (Bees Wax)

    1. Chemical vasoconstrictors (epi)

Racellets and Epi: Cotton impregnated w/ racemic epi. (immediate vasoconstriction) little systemic absorption. Placed on bone w/ another cotton pellet and pressure for 2-4 minutes.
Discuss hemostasis during surgery
b. Chemical vasoconstrictors (epi)

Racellets and Epi:

Vickers/Baumgartner - Effective hemostasis, No significant cardiovascular effects (#3 Racellet = 0.55 mg racemic epi/pellet)
Ferric sulfate:

Jeansonne/Lemon - Agglutination of blood proteins that occlude capillary orifices. Cytotoxic and causes tissue necrosis therefore it must be removed to prevent delayed healing

Vickers/Baumgartner - Effective hemostasis, No significant cardiovascular effects

Not studied for endodontic applications

Discuss hemostasis during surgery

c. Absorbable hemostatic agents

Calcium sulfate: Tamponade effect, biocompatible, resorbs in 2-4 weeks

Scarano 2012
Gelfoam: Animal skin gelatin, promotes platelet disintegration. Stimulates thromboplastin release and thrombin formation. Not applicable to endo surgery.
Collagen: Causes platelet aggregation & fibrin formation. If applied directed w/ pressure = hemostasis in 2-5 mins. Does not inhibit healing. Vy/Baumgartner - CollaCote+ 2.25% racemic epi – No significant cardiovascular effects, effective hemostasis
Surgicel: Oxidized regenerated cellulose. Acts mechanically by forming a sticky mass when in contact with blood. Inhibits healing & stimulates Inflammation. Not recommended.

How much blood is lost during periapical surgery?

  1. Messer EDT 1987Operating time was the biggest factor influencing blood loss (increased loss with increased time) Blood loss avg. = 9.5 mL, range 1.2 - 48.4 mL. (comparable to single tooth extraction)

  1. Buckley J Perio 1984 – Study indicated significant reduction of blood loss using 1:50k vs 1:100k epi. (50% less blood loss)

  1. Lindorf OOO 1979 – This study discussed the rebound effect (reactive hyperemia) following injections with epi.

Discuss CHX and Surgery

  1. Vaughan/Garnick 19890.12% CHX reduced plaque and gingival inflammation up to 2 weeks after Periodontal surgery

Does removing the smear layer on the resected root end improve post surgical healing?

  1. Craig/Harrison JOE 1993 - Demineralizing the root end with citric acid enhances cementogenesis and dentoalveolar healing in dogs. It acts by exposing collagen fibrils of the resected cementum and dentin. (50% citric acid, pH 1, 2 min)


  1. Jeansonne JOE 2003NSD in healing or bone fill when citric acid or tetracycline were used to remove the smear layer (at 9 or 18 days).

  1. Zhu JOE 2000Cell adhesion of osteoblasts is NOT influenced by the existence of a smear layer or the direction of the dentinal tubules (bevel angle) on the dentin surface.

Discuss some different retrofilling materials besides SEBA and MTA

  1. Andreasen JOE 1993Studied composite retrofill, produced reformation of periodontium including reformation of a lamina dura, inserting Sharpey’s fibers and cementum deposition.

  2. Chong IEJ 1997 – Studied Vitrebond vs ZOE vs Amalgam. Best results with Vitrebond in dog teeth.

  3. Olsen JOE 1994 – Materials study impanted in rats – IRM, Amalgam and EBA. IRM & amalgam had complete healing in 56 days. EBA greater inflammation initially, all had complete healing in 100 days.

  4. Gutmann IEJ 1997Diaket superior seal to amalgam, degree of bevel did not influence leakage, sonic prep larger than bur prep

  5. Johnson OOO 1999 – Problem with amalgam as a retrograde material – toxicity, delayed expansion/ corrosion, tissue staining, and leakage.

  6. Zhu JOE 1999Amalgam more cytotoxic to human PDL cells and human osteoblast-like cells than IRM or SEBA.

Why use SEBA?

Ease of handling, less washout, good seal, biocompatibility, proven track record

  1. Adamo IEJ 1999 – Comparative study: MTA, SEBA, Composite and Amalgam as a root end filling materials – results indicated NSD in leakage between all materials.

  1. Jeansonne JOE 2003SEBA & MTA leaked less than amalgam

  1. Dorn JOE 1990 – Results of study demonstrated greater success with use of SEBA (95%) vs IRM (91%) vs amalgam (75%)

  1. Torabinejad JOE 1995 – confirmed biocompatablilty of SEBA and MTA

  1. Trope OOO 1996SEBA superior to glass ionomer, amalgam, IRM and composite as retrofilling material

Super EBA vs. MTA for Root End Filling
MTA > Super EBA:

  1. Von Arx 2012 Prospective, Apical Microsurgery, 170 teeth, Healing @ 5 year follow up: MTA 86%, Super EBA: 67%; Signficiant difference in healing between MTA & Super EBA

  2. Tsesis 2013Meta-Analysis (modern techniques), MTA  success of Surgery compared to SuperEBA, IRM, Amalgam for retrofill

  3. Torabinejad 1993 – MTA > SEBA or Amalgam for root end filling

MTA = Super EBA:

  1. Song 2012 – EMS, 260 teeth, Prospective randomized clinical trial, MTA vs. Super EBA, 12 month follow up, MTA: 95.6%, SuperEBA: 93.1%; No significant difference in healing (clinical/radiographic) … does NOT account for “Late Failures”

What is MTA?


  1. Dicalcium silicate

  2. Tricalcium silicate

  3. Tricalcium aluminate

  4. Bismuth oxide

  5. Tetra calcium aluminoferrite (not in white MTA)

  6. Calcium sulfate hydrate (gypsum)

Gray vs. White MTA

  1. Faraco/Holland – Both White and Grey MTA demonstrated complete dentin bridge formation in dog pulp capping

  2. Parirokh – Both White and Grey MTA demonstrated hard tissue barrier formation and no inflammation

  3. Camilleri – Both White and Grey MTA demonstrated comparable biocompatibilities and osteogenic properties

Discuss studies using MTA for root end fillings –

  1. Torabinejad JOE 1993MTA showed less leakage than SEBA, IRM, or Amalgam (See also Fischer/Miller 1998)

    1. Advantages of MTA:

      1. Easy to mix

      2. Dry field not required

      3. Excess is easy to remove

      4. Less periradicular inflammation than amalgam

      5. Cementum found on surface after healing

      6. Less bacterial or endotoxin leakage than amalgam, SEBA or IRM (90 days)

      7. Will not be effected by resection after it sets (cut thru material)

    2. Disadvantages of MTA

      1. Long setting time – 3 hours

Discuss studies using MTA for root end fillings –

  1. Christiansen IEJ 2009Randomized Clincal Trial: 44 patients: 2 groups: 1) 3 mm Retroprep/MTA retrofill, 2) Burnished GP w/No retroprep/fill. Healing (1 yr follow up): MTA (1): 96%, GP (2): 52%

  1. Tsesis 2013 – Meta-Analysis, MTA  success compared to other material

  1. Wu/Wesselink – 24 hrs: GI>Amalgam>MTA = SEBA; 1 year: MTA>GI>SEBA>Amalgam

  1. Von Arx 2012 5 yr apical microsurgery outcome study: MTA root end filling: 86%, Super EBA: 67%

  1. Baek 2005 – Dog study, Root end retrofill: MTA>SEBA>Amalgam for Cementum attachment, cementum growth, degree/type of inflammation, and PDL reformation around the resected root end


  1. Parirokh 2006 – Review of MTA properties and clinical applications

  1. Yesilsoy – 45 mins to set

  1. Holland/de Souza 1999/2002 – Histopathologic dog studies – MTA exhibited inflammation (vs. CaOH2), complete hard tissue barrier formation, and cementum attachment directly to MTA

  1. BaikPDL cells closely attach to MTA

  1. de Souza/Costa 2008 – less cellular toxicity than CaOH2

  1. Yasuda 2007MTA vs Dycal, MTA  Bone morphogenetic protein (BMP2) production, Dycal  BMP2 production and  cell death

  1. Lovato/Sedgley 2011Antibacterial effect of MTA against E. facaelis

Discuss Bioceramics and EndoSequence Root Repair Material

Only manufacturer and in Vitro studies to this point. No outcome studies!


  1. Bioceramics = Calcium silicate, Calcium Phosphate bioactive material

  2. Nanospheres and hydrophilic nature allow dentinal tubule penetration

  3. Mechanical bond with dentin

  4. Biocompatibility = MTA (Damas/Hoen, Ma/Haapasalo)

  5. Exceptional dimensional stability (no shrinkage)

  6. Antibacterial: High pH (12.8), CaOH2 diffusion (Nasseh 2013)

  1. Hess – Sealer NOT retreatable with current methods – solvents, files, heat

  2. Ma/Haapasalo – ESRR Putty/Paste similar cell viability as MTA (fibroblasts)

  3. Damas/Hoen – ESRR Putty/Paste similar cell viability as MTA (fibroblasts)

  4. Modarezdeh – MTA > Geristore > ESRRM (odontoblastic viability and ALP expression)

  5. Charland/Hartwell – MTA set at 36 hours, ESRRM NOT set at 48 hours!

  6. Lovato/Sedgley – MTA and ESRRM have antibacterial properties - E. faecalis

Discuss healing after surgery
Phases of Healing:

  1. Inflammatory: 1-3 daysFibrin clot, Epithelial seal/barrier, PMNs (24-48 hrs), Macrophages (48-96 hrs) – Innate immune response

  1. Proliferative: 3-5 daysGranulation tissue (day 4), Fibroblasts, Endothelial cells, variable number of macrophages and lymphocytes (T & B cells) – Adaptive immune response

  1. Maturation: 5-14 days – Collagen Formation, Angiogenesis, Re-organization, Fibrous CT replaces granulation tissue

Discuss healing after surgery

Harrison/Jurosky 1991 & 1992 JOE – Monkey studies of surgical healing

3 phases (CEC): Clotting/inflammation, Epithelial healing, CT healing

  1. Incisional wound – Intrasulcular incision leaves thin layer of connective tissue and epithelium attached to root surface after reflection. Preservation of this tissue prevents epithelial down-growth along root surface and loss of attachment.

    1. Day 1: Fibrin Clot, PMNs

    2. Day 2: Epithelial seal, Macrophages

    3. Day 3: Epithelial barrier, Fibroblasts, Macrophages

    4. Day 4: Granulation tissue w/collagen formation and Proliferation

    5. Day 14: Replacement of granulation tissue by fibrous CT

CT heals by 14 days!

Submarginal and intrasulcular flaps heal equally well (Refutes Kramper/Kaminsky).

Discuss healing after surgery

Harrison/Jurosky 1991 & 1992 JOE

3 phases (CCB): Clotting/inflammation, CT healing, Bone Healing

  1. Dissectional wound – healing occurs slower than incisional wound. Periosteum does not survive flap reflection. Don’t curette cortical-retained periosteal tissues, they are a source of reattachment. Crestal bone height is not altered (refutes Wood, Kramper/Kaminsky)

    1. Day 1: Fibrin Clot, PMNs, cortical necrosis of denuded areas

    2. Day 2: PMNs, Macrophages, Fibroblasts, No osteoclastic/osteoblastic activity

    3. Day 3: Macrophages, Fibroblasts, Collagen formation

    4. Day 4: Granulation tissue, Macrophages, collagen formation, No osteoclastic/osteoblastic activity on the cortical surface

    5. Day 14: Replacement of granulation tissue by fibrous CT, new periosteum formed, osteoclastic/blastic activity!

    6. Day 28: Flapped tissue normal, continued osteoclastic/blastic activity on the periosteal surface of crestal bone (PDL side heal)

Discuss healing after surgery

Harrison/Jurosky 1991 & 1992 JOE

  1. Osseous woundNew bone matrix was formed directly on devitalized bone surface. Periosteum separates overlying mucosa from excisional wound site and does not function until excisional wound is filled with woven (cancellous) bone of endosteal origin.

    1. Day 1-3: Coagulum consisting of erythrocytes, some inflammatory cells, and tissue debris

    2. Day 4: Proliferation of cancellous bone of endosteal origin into wound site, Macrophages, PMNs, Fibroblasts within coagulum. Central core of coagulum devoid of vital cells

    3. Day 14: Cancellous bone occupied 4/5ths of wound, osteoblastic activity throughout, appositional growth on both cortical and cancellous devitalized bone surfaces

    4. Day 28: Maturing trabecular bone predominates, delimiting membrane separates, osteoid deposited on inner endosteal and outer periosteal layers

Discuss healing after surgery
Lin/Langeland 1996 IEJ – It is NOT necessary to completely curette out all of the inflamed periradicular tissue during surgery, but removal of foreign objects is required for resolution of a lesion.
Corcoran 1984 JOE – Monkey study, Bone healing, demonstrated 16 week results post op from apical surgery to be the same as undisturbed bone.

(C.V. for bone healing = 16 weeks)

Von ArxCementum: Start: 10-12 days, Completion: 28 days; Bone: Start: 7 days (Harrison/Jurosky – day 4), Completion: 16 weeks (4 months)
Wood 1972Full thickness mucoperiosteal flap results in loss of 0.5 mm of crestal bone height
Zimmerman/Velvart 2001Full thickness mucoperiosteal flap healing results in recession of marginal gingiva and papilla shrinkage

Discuss Suture Selection (LSK)

  1. Lilly 1968/69Monofilament (ie: Nylon, Gut) produced less inflammatory tissue responses than Multifilament (ie: Silk, Polyester)

  1. Selvig 1998Monofilament sutures are least traumatic/bacterial adhering (Nylon, PTFE); Sutures should be removed at 48-72 hours, Post 72 hours = Inflammation and Resealing of epithelium (epithelial barrier day 3)

  1. Torbejork – Vicryl poly galactin 9/0

  1. Kim5-0 or 6-0 Monofilament Nylon Or Propylene i.e.: Vicryl (MNOP) to prevent inflammation

Monofilament = Nylon, Gut, Propylene (Vicryl, PTFE)

Multifilament = Silk, Polyester
What is enamel matrix derivative ?
Emdogain: a protein gel that has been shown to promote acellular cementum formation, which is the first step in regeneration of the attachment apparatus.

  1. Nakamura 2002 IEJ – Pig study; Compared Emdogain and Dycal for pulpotomy – Emdogain had better pulpal healing and greater dentin formation than Dycal

  1. Iqbal/Bamaas 2001 Dent Traum – Dog study; Evaluated Emdogain in replantation cases of extended extraoral dry time. Emdogain increased resistance to root resorption/ankylosis and stimulated healing of the PDL. (supported by Trope)

  1. Hamamoto 2002 Dent Traum – EMD is accumulated in the cells at the root surface and promotes regeneration of the periodontal tissues and healing of root resorption

Discuss GTR in endodontic surgery

CaSO4 (Calcium Sulfate)

  1. Suda 2002 IEJ – Dog study – CaSO4 was effective in bone regeneration on both large osseous defects and “through and through” osseous defects. It was less effective in osseous defects communicating with the gingival sulcus.

  1. Pecora 1997 OOO – Rat study - CaSO4 barrier impedes connective tissue ingrowth, allowing bone regeneration during healing; Use in: >10 mm lesions, through and through lesions, endo-perio defects

  1. Apaydin/Torabinejad 2004 JOE – Dog study – CaSO4 does NOT improve cementum deposition/osseous healing

  1. Dahlin – Useful in through and through defects

  1. Oh/Fouad – Useful in Pathologic dehiscence

Discuss GTR in endodontic surgery

GTR is beneficial

  1. Pecora 1997 DCNA – Indications for GTR (Gortex membrane) in endodontic surgery include (same as for CaSO4):

    1. Large periapical lesion >10 mm

    2. Through and through periapical lesion

    3. Endo-perio defects

      1. Periapical lesion communicating with alveolar crest (dehiscence)

      2. Furcation involvement as a result of perforation

      3. Root perforation with bone loss to alveolar crest

*Periradicular healing occurred more rapidly with GTR membranes

  1. Gutman 2001 JOE – Dog study w/Guidor – bioresorbable membrane enhances apical regeneration of bone, ct attachment and marginal bone

  1. Tsesis 2011 JOESys Review/Meta-Analysis, GTR favorable for large periapical lesions, through and through lesions. Resorbable membranes.

Discuss GTR in endodontic surgery
GTR is not needed

  1. Hartwell 2002 JOE – human study in vivo – NSD between rate of healing with or without GTR. No beneficial effects on rate of healing.

  1. Torabinejad 1998 JOE – Cat study – GTR exhibited more inflammation, no positive effect on osseous healing or new cementum formation.

Discuss Apical Decompression

Neaverth/Burg 1982:

Marsupialization = Unroofing outer wall of cyst by making an incision, evacuating contents and establishing permanent opening by suturing cystic membrane to mucosal surface; slower healing; not useful in radicular cysts
Decompression = No exteriorization of cystic wall; incision into cystic cavity, indwelling catheter (tubing) placed to maintain patency of opening and allow irrigation, drainage of fluids/metabolic byproducts, and reduction of lesion
Decompression is done to avoid:

    1. Devitalization of adjacent teeth

    2. Damage to anatomic structures (IAN, Sinus)

    3. Loss of bony support

    4. Parasthesia

    5. Elderly pts where surgery is risky

    6. Enucleation and more extensive surgeries

Discuss Apical Decompression

  1. Freedland 1970 – Use polyvinyl tubing for maintaing patency and irrigation of large PA cystic lesions

  1. Neaverth/Burg JOE 1982 – Case reports; Use of radiopaque catheter polyvinyl tubing (size 8FR – lumen diameter: 1.5 mm, length: 2 inches)

  1. Martin JOE 2007 – Case report (13 yo/#9), large PARL, Protocol: NSRCT/CaOH2, GP obturation, return of sinus tract, Incision/Drain placement (size 10FR radiopaque surgical latex tubing, lumen diameter: 1.5 mm), sutures to close incision and stabilize drain, Irrigation protocol: 0.12% CHX rinse with syringe once daily, Drain removed at 6 weeks. Recalled every 3 months, complete healing at 2 years.

Are root amputations an option to avoid extraction?


  1. Smukler 1976 – RCT prior to surgical root amp is treatment of choice but vital root amps are successful if RCT is done within 2 weeks of amputation.

  2. Blomlof 1997 – prognosis of root-resection is comparable to single-rooted teeth with an equal susceptibility to periodontitis, if endodontic conditions an maintenance care are optimal.

  3. Basten 1996 - 92% of all resected molars survived an average of 12 years.

Vital Root Amputation

  1. FilipowiczNecrosis: 12 months: 38%, 5 years: 87%

  1. England/Hartwell

  1. Langer – 5 year survival: 18%

Discuss intentional replantation. What is the prognosis?

  1. Kratchman 1997 – Dental Clinics of North America – Success rate 80-85%

  1. Grossman – 70% at 5 years

  1. Bender & Rossman - 81% Success

  1. Yoshino – 80% Success;  Success for younger pts and Males

Anti-platelet medications and Apical Surgery

  1. Napeñas – Do NOT take patient off of anti-platelet meds - plavix (clopidogrel) or aspirin - prior to apical surgery. Risks of discont. Meds prior to surgery far outweigh low risk of post-op complications with bleeding.


What is the incidence of traumatic dental injuries?

  1. Glendor 1996Avulsions of permanent teeth seen 0.5 – 3% of all dental injuries

  1. Glendor 2008Maxillary central and lateral incisors are most commonly avulsed

  1. Andreasen 1970Avulsions account for up to 16% of traumatic injuries to permanent dentition

  1. Ravn/Andreasen22% schoolchildren experience at Traumatic Dental Injury

  1. Kaba 201011% children (6-18 yrs) experience dental truama

Discuss non-complicated crown fractures
Ravn 1981 – Retrospective study of incisors w/ enamel-dentin fractures

  1. Pulp necrosis developed in 6.1%

  2. If concussion & mobility – pulpal necrosis in 30.1%

  3. Prognosis depends not only on damage to tooth but damage to periodontium

  4. Most changes in vitality occur in the 1st 6 months.

Kaba 201012% enamel-dentin fractures led to pulpal necrosis
Sensibility tests: +

Mobility: Normal, Percussion: - (if + evaluate for root fx or luxation)

Radiographs: Occlusal film (rule out root fx), 2 PAs: Mesial/Distal

Discuss complicated crown fractures
Cvek 1982 JOEMonkey study – Inflammatory reactions of pulp exposures from fractures or cavity preps at different times. Crown-fractured teeth with vital pulp exposures up to a period of 7 days, no more than 2 mm of pulp beneath the exposure needs to be removed.

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