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JUNE.2004.VOL.32.NO.6.CDA.JOURNAL 485
Contemporary Endodontic Surgery
Richard Rubinstein, DDS, MS; and Mahmoud Torabinejad, DMD, MSD, PhD

Authors / Richard Rubinstein, DDS, MS, is adjunct assistant professor in the Department of Endodontics at the University
of Pennsylvania School of Dentistry and an adjunct clinical professor at the Rackham School of Graduate Studies at the
University of Michigan School of Dentistry in Ann Arbor, Mich. He has written numerous scientific articles on the surgical
operating microscope and endodontic microsurgical technique; a contributing author to Endodontics, fourth and fifth editions,
and Microscopes in Endodontics in The Dental Clinics Of North America.

Mahmoud Torabinejad, DMD, MSD, PhD, is a professor of endodontics and director of Graduate Endodontics at Loma Linda
University School of Dentistry, and practices in Upland, Calif. He has coauthored two textbooks in nonsurgical
and surgical endodontics as well as numerous articles on endodontics and dental topics. He was certified as a diplomate of
the American Board of Endodontists and taught at Harvard before joining Loma Linda University. He has received several
awards including Ralph F. Somers, Louis I. Grossman, and the Philanthropist award of the AAE Foundation.

Abstract

During the past decade, endodontics has seen a dramatic shift in the application of periradicular surgery and the role it
plays in endodontic treatment. With the introduction of enhanced magnification, periradicular ultrasonics and other
associative technologies, teeth that might otherwise be extracted now have a chance for retention. This article describes
the role of these advances in contemporary endodontic surgery. onsurgical root canal therapy is a highly successful
procedure if diagnosis and technical aspects are carefully performed.

There is a common belief that if root canal therapy fails, surgery is indicated for correction. This is not always true;
most failures are best corrected by retreatment. Studies have shown that a majority of retreated cases are successful
following retreatment.1-5 There are, however, situations in which surgery is necessary to retain a tooth that would
otherwise be extracted.

The purpose of this article is to briefly describe indications and contraindications as well as the steps involved and new
advances in periradicular surgery. The details for this procedure can be found in surgical and nonsurgical endodontic text
books.6-8 Indications and Contraindications for Periradicular Surgery The main indications for periradicular surgery are:
complex root canal anatomy, procedural accidents (Figure 1), irretrievable materials in the root canal (Figure 2), symptomatic
cases, horizontal apical fracture, biopsy (Figure 3) and corrective surgery (Figure 4). Contraindications are relatively
few. There are four major categories: (1) anatomic factors, (2) medical or systemic complications, (3) indiscriminate use of
surgery, and (4) unidentified cause of treatment failure. Steps in Periradicular Surgery The typical sequence of procedures
used in periradicular surgery are flap design, incision and reflection, apical access, periradicular curettage, root-end resection,
root-end cavity preparation, root-end filling, flap replacement and suturing, postoperative care and instructions, suture removal
and evaluation. Recent Advances in Endodontic Surgery

Many advances in surgical technique and instrumentation have occurred over the past decade. They include enhanced magnification
and illumination, ultrasonic tips, ............

1. Witherspoon, D.E. and K. Ham,
One-visit apexification: technique for inducing root-end barrier formation in apical closures. 
Pract Proced Aesthet Dent, 2001. 13(6): p. 455-60; quiz 462.

Numerous procedures and materials have been utilized to induce
root-end barrier formation. Mineral trioxide aggregate (MTA) was
introduced to dentistry as a root-end filling material. It has been
advocated for filling root canals, repairing perforations, pulp
capping, and root-end induction. Mineral trioxide aggregate reacts
with tissue fluids to form a hard tissue apical barrier. As a result,
MTA shows promise as a valuable material for use in one-visit
apexification treatment, primarily for treating immature teeth with
necrotic pulps.

2. Schmitt, D., J. Lee, and G. Bogen,
Multifaceted use of ProRoot MTA root canal repair material. 
Pediatr Dent, 2001. 23(4): p. 326-30.

Mineral Trioxide Aggregate (MTA) is a new material recently approved
by the FDA for use in pulpal therapy. MTA has been reported to have
superior biocompatibility and sealing ability and is less cytotoxic
than other materials currently used in pulpal therapy. This report is
a review of MTA's physical and biological properties and the clinical
techniques of direct pulp capping, apexification, and repair of failed
calcium hydroxide therapy.

3. Roda, R.S.,
Root perforation repair: surgical and nonsurgical management. 
Pract Proced Aesthet Dent, 2001. 13(6): p.467-72; quiz 474.

Root perforation repair has historically been an unpredictable
treatment modality with an unacceptably high rate of clinical failure.
Recent developments in the techniques and materials utilized in root
perforation repair have dramatically enhanced the prognosis of both
surgical and nonsurgical procedures. This article presents a review of
the literature pertaining to root perforation repair and illustrates,
through clinical case presentations, the principles of extraradicular
surgical repair and non-surgical internal repair of root perforation
using mineral trioxide aggregate (MTA).

4. O'Sullivan, S.M. and G.R. Hartwell,
Obturation of a retained primary mandibular second molar using mineral trioxide aggregate: a case report. 
J Endod, 2001. 27(11): p. 703-5.

This case report demonstrates Mineral Trioxide Aggregate obturation of
the root canal system of a retained primary mandibular second molar
where no succedaneous permanent tooth was present. The technique
seemed to provide a biocompatible seal of the root canal system in
this case. It is not recommended for obturation of primary teeth that
are expected to exfoliate since it is anticipated that Mineral
Trioxide Aggregate would be absorbed slowly, if at all.

5. Koh, E.T., et al.,
Prophylactic treatment of dens evaginatus using mineral trioxide aggregate. 
J Endod, 2001. 27(8): p. 540-2.

Two case reports with dens evaginatus are presented. Each patient had
one tooth affected. There was a prominent tubercle on the occlusal
surface of the mandibular second premolar. Under local anesthesia and
rubber dam isolation a partial pulpotomy was conducted and mineral
trioxide aggregate was placed. After 6 months the teeth were removed
as part of planned orthodontic treatment. Histological examination of
these teeth showed an apparent continuous dentin bridge formation in
both teeth, and the pulps were free of inflammation. These cases show
that mineral trioxide aggregate can be used as an alternative to
existing materials in the proplylactic treatment of dens evaginatus.

6.Holland, R., et al.,
Mineral trioxide aggregate repair of lateral root perforations. 
J Endod, 2001. 27(4): p. 281-4.

This study was conducted to observe the healing process of intentional
lateral root perforation repaired with mineral trioxide aggregate
(MTA). Forty-eight root canals of dogs' teeth were instrumented and
filled. After partial removal of the filling, an intentional
perforation was made with a bur in the lateral area of the root. The
perforations were repaired with MTA or Sealapex (control group).
Histological analysis occurred 30 and 180 days after treatment.
Results showed no inflammation and deposition of cementum over MTA in
the majority of the specimens. In the 180-day period, Sealapex
exhibited chronic inflammation in all the specimens and slight
deposition of cementum over the material in only three cases. In
conclusion, MTA exhibited better results than the control group.

7. Koh, E.T.,
Mineral trioxide aggregate (MTA) as a root end filling
material in apical surgery--a case report. 
Singapore Dent J, 2000.23(1 Suppl): p. 72-8.

Many root end filling materials for apical surgeries have been
identified either for scientific evaluation or clinical usage but none
meets the requirements of an ideal root end filling material. Recently
a new cement, Mineral Trioxide Aggregate (MTA) was researched as a
potential root end filling material and showed promising results. This
paper reports the significant findings of research done on MTA as a
root end filling material and presents a clinical case where apical
surgery was performed using MTA as retrograde filling.

8. Schwartz, R.S., et al.,
Mineral trioxide aggregate: a new material for endodontics. 
J Am Dent Assoc, 1999. 130(7): p. 967-75.

BACKGROUND: Mineral trioxide aggregate, or MTA, is a new material
developed for endodontics that appears to be a significant improvement
over other materials for procedures in bone. It is the first
restorative material that consistently allows for the overgrowth of
cementum, and it may facilitate the regeneration of the periodontal
ligament.
CASE DESCRIPTION: The authors present five cases in which MTA was used
to manage clinical problems. These included vertical root fracture,
apexification, perforation repair and repair of a resorptive defect.
In each case, MTA allowed bone healing and elimination of clinical
symptoms.
CLINICAL IMPLICATIONS: Materials such as zinc oxide-eugenol cement and
resin composite have been used in the past to repair root defects, but
their use resulted in the formation of fibrous connective tissue
adjacent to the bone. Because it allows the overgrowth of cementum and
periodontal ligament, MTA may be an ideal material for certain
endodontic procedures.

9. Torabinejad, M. and N. Chivian,
Clinical applications of mineral trioxide aggregate. 
J Endod, 1999. 25(3): p. 197-205.

An experimental material, mineral trioxide aggregate (MTA), has
recently been investigated as a potential alternative restorative
material to the presently used materials in endodontics. Several in
vitro and in vivo studies have shown that MTA prevents microleakage,
is biocompatible, and promotes regeneration of the original tissues
when it is placed in contact with the dental pulp or periradicular
tissues. This article describes the clinical procedures for
application of MTA in capping of pulps with reversible pulpitis,
apexification, repair of root perforations nonsurgically and
surgically, as well as its use as a root-end filling material.

10. Behnia, A., H.E. Strassler, and R. Campbell,
Repairing iatrogenic root perforations. 
J Am Dent Assoc, 2000. 131(2): p. 196-201.

BACKGROUND: Post preparation is an integral part of restoring
endodontically treated teeth in indicated cases. Iatrogenic
perforation of the root can result from preparing post space and can
severely compromise the prognosis of the tooth.

CASE DESCRIPTION: Two years after a patient's maxillary lateral
incisor was restored with a post-retained composite resin, he went to
a dental school emergency clinic with a chief complaint of soft-tissue
swelling adjacent to the tooth. The authors took a periapical
radiograph that revealed evidence of a circumscribed radiolucent
lesion associated with the distal midroot area and a periapical
radiolucency. Based on the radiograph, the authors suspected that the
canal preparation for the post and the post placement had perforated
the root at the base of the post.

CLINICAL IMPLICATIONS: The authors used a combined surgical and
orthograde approach with a biocompatible restorative material and a
clear, plastic light-transmitting post to repair the iatrogenic
perforation.

11. Blackler, S.M.,
Space maintenance--a review of treatment options to repair the iatrogenic perforation. 
Ann R Australas Coll Dent Surg, 2000. 15: p. 252-3.

Management of intra-canal and furcation perforations can pose a
significant clinical challenge. In such cases a biological matrix can
provide the framework for healing of injured periodontal tissues and
will facilitate placement of the perforation repair material. As a
consequence the long-term prognosis for treatment of the iatrogenic
perforation can be significantly improved and the need for surgical
intervention can often be eliminated.

12. Germain, L.P.,
Mineral trioxide aggregate: a new material for the new millennium. 
Dent Today, 1999. 18(1): p. 66-7, 70-1.

A midroot strip perforation can be a difficult problem to treat.
Surgical treatment is arduous and has a poor prognosis. Variable
success has been seen with the classic repair materials for
nonsurgical treatment. Mineral trioxide aggregate seems to have
incredible promise for sealing these defects with a good long-term
prognosis.

13.Bruder, G.A., 3rd, et al.,
Perforation repairs. 
N Y State Dent J, 1999. 65(5): p. 26-7.

Management of instrument perforations in the periodontal ligament
space during endodontic or restorative procedures is an ongoing
problem in dentistry. The introduction of microscopes, new instruments
and materials has resulted in more controllable and predictable
surgical and nonsurgical outcomes. This paper discusses some of the
newer techniques and materials used to manage perforations effectively.

14.Arens, D.E. and M.
Torabinejad, Repair of furcal perforations with mineral trioxide aggregate:
two case reports. 
Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 1996. 82(1): p. 84-8.

Furcal perforation is an unfortunate incident that can occur during
root canal therapy or post preparation of multirooted teeth. Studies
have shown that the materials currently used to repair these
iatrogenic accidents are inadequate. The poor prognosis of furcation
perforations is probably due to bacterial leakage or lack of
biocompatibility of repair materials. On the basis of the recent
physical and biologic property studies of the newly introduced mineral
trioxide aggregate, this material may be suitable for closing the
communication between the pulp chamber and the underlying periodontal
tissues. These case reports support this hypothesis.

15. Valavanis, D.K. and G.N. Spyropoulos,
[Perforation during endodontic treatment]. 
Hell Stomatol Chron, 1989. 33(1): p. 57-65.

Perforations of the pulp chamber wall and area of root may occur
during access opening of the pulp chamber and during root canal
instrumentation. The authors in this paper describe in details the
factors that can lead to perforations of pulp chamber or area of the
root, the treatment and factors that affecting the repair and the
prognosis of the perforations.

16.Ford, T.R., et al.,
Use of mineral trioxide aggregate for repair of furcal perforations. 
Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 1995. 79(6): p. 756-63.

The histologic response to intentional perforation in the furcations
of 28 mandibular premolars in seven dogs was investigated. In half the
teeth, the perforations were repaired immediately with either amalgam
or mineral trioxide aggregate; in the rest the perforations were left
open to salivary contamination before repair. All repaired
perforations were left for 4 months before histologic examination of
vertical sections through the site. In the immediately repaired group,
all the amalgam specimens were associated with inflammation, whereas
only one of six with mineral trioxide aggregate was; further, the five
noninflamed mineral trioxide aggregate specimens had some cementum
over the repair material. In the delayed group, all the amalgam
specimens were associated with inflammation; in contrast only four of
seven filled with the aggregate were inflamed. On the basis of these
results, it appears that mineral trioxide aggregate is a far more
suitable material than amalgam for perforation repair, particularly
when used immediately after perforation.