Syngcuk Kim, DDS, PhD, MD (Hon), is Louis I. Grossman Professor and Chairman Emeritus in the Department of Endodontics and Associate Dean for Global Affairs at the University of Pennsylvania School of Dental Medicine in Philadelphia, Pennsylvania, USA, and maintains a private practice in New York, New York, USA.

Samuel Kratchman, DMD, is Clinical Associate Professor and Assistant Director of Graduate Endodontics and Director of Microsurgery in the Department of Endodontics at the University of Pennsylvania School of Dental Medicine in Philadelphia, Pennsylvania, USA, and maintains three private practices limited to endodontics in Exton, West Chester, and Paoli, Pennsylvania, USA.

Associate Editors
Bekir Karabucak, DMD, MS, is Chair and Associate Professor of Endodontics, Director of the Postdoctoral Endodontics Program, and Director of the Division of Advanced Dental Education at the University of Pennsylvania School of Dental Medicine in Philadelphia, Pennsylvania, USA, and maintains a private practice in Philadelphia, Pennsylvania, USA.

Meetu Kohli, DMD, is Clinical Associate Professor of Endodontics and Director of the Continuing Education and International Program in the Department of Endodontics at the University of Pennsylvania School of Dental Medicine in Philadelphia, Pennsylvania, USA, and maintains two private practices limited to endodontics in Oaks and Gilbertsville, Pennsylvania, USA.

Frank Setzer, DMD, PhD, MS, is an Assistant Professor, Clinical Director, and Pre-Doctoral Program Director in the Department of Endodontics at the University of Pennsylvania School of Dental Medicine in Philadelphia, Pennsylvania, USA, and maintains a private practice in Philadelphia, Pennsylvania, USA.

Contributors xiii Preface xv Acknowledgements xvii 1 The Dental Operating Microscope 1Frank Setzer 1.1 Benefits of the Operating Microscope 1 1.2 Key Features of Operating Microscopes 1 1.3 Customizing a Microscope 3 1.3.1 Light Source 3 1.3.2 Documentation 5 1.3.3 Individual Microscope Adjustment (Parfocaling) 5 Suggested Readings 7 2 Microsurgical Instruments 9SeungHo Baek and Syngcuk Kim 2.1 Examination Instruments 9 2.2 Incision and Elevation Instrument 9 2.3 Tissue Retraction Instruments 11 2.4 Osteotomy Instruments 14 2.5 Curettage Instruments 14 2.6 Inspection Instruments 15 2.7 Ultrasonic Units and Tips for Root End Preparation 17 2.8 Microplugger Instruments 20 2.9 Suturing Instruments 20 2.10 Miscellaneous Instruments 22 3 Medication-Related Osteonecrosis of the Jaw and Endodontic Microsurgery 25Chafic Safi and Bekir Karabucak Suggested Readings 29 4 Indications and Contraindications 31Bekir Karabucak and Garrett Guess 4.1 Introduction 31 4.2 Surgical Success Dependent on Ability to Perform Ideal Protocols 31 4.3 Etiology Assessment through Examination and Treatment 31 4.4 Periodontal Considerations and Surgery 33 4.5 Influential Patient Factors 33 4.6 Condition of Previous Endodontic Treatment 37 Suggested Readings 38 5 Anesthesia and Hemostasis 39Siva Rethnam-Haug, Aleksander Iofin, and Syngcuk Kim 5.1 Armamentarium 39 5.1.1 Epinephrine 39 5.2 Presurgical Phase 40 5.2.1 Administration of Local Anesthetic 40 5.2.2 Injection Techniques 40 5.2.3 Topical Anesthesia 41 5.2.4 Additional Techniques 41 5.2.5 Maxillary Anesthesia 41 5.2.6 Mandibular Anesthesia 43 5.2.7 Bilateral Mandibular Surgery 43 5.3 Surgical Phase 44 5.3.1 Topical Hemostatic Agents 44 5.3.1.1 Epinephrine Pellets 45 5.3.1.2 Ferric Sulfate 45 5.4 Summary of Hemostatic Techniques in Endodontic Microsurgery 46 5.5 Postsurgical Phase 46 Suggested Readings 48 6 Flap Design in Endodontic Microsurgery 49Francesco Maggiore and Frank Setzer 6.1 Armamentarium 49 6.1.1 Flap Outline 49 6.1.2 Papilla Management 52 6.1.3 Incision 54 6.1.4 Flap Elevation 54 6.1.5 Flap Retraction 55 Suggested Readings 56 7 Osteotomy 57Francesco Maggiore and Syngcuk Kim 7.1 Armamentarium 57 7.2 Osteotomy 57 7.2.1 Distinction between Bone and Root Tip 57 7.2.2 Clinical Situations for Endodontic Microsurgery 58 7.3 Intact Cortical Plate without a Radiographic Periapical Lesion 59 7.4 Intact Cortical Plate with a Periapical Lesion 60 7.5 Fenestration through the Cortical Plate Leading to the Apex 60 7.5.1 Optimal Osteotomy Size 61 7.5.2 Key Hole Osteotomy Modification 61 7.5.3 BoneWindow Technique 61 8 Root End Resection 67Spyros Floratos, Fouad Al-Malki, and Syngcuk Kim 8.1 Armamentarium 67 8.2 Root End Resection 67 8.3 Root End Resection: Steep Bevel versus Shallow Bevel 69 Suggested Readings 72 9 Inspection of the Resected Root Surface: Importance of Isthmus 73Spyros Floratos, Jorge Vera, Fouad Al-Malki, and Syngcuk Kim 9.1 Armamentarium 73 9.1.1 Methylene Blue Staining (MBS) 73 9.1.2 Isthmus 77 9.1.3 Types of Isthmus 77 9.1.4 Incidence 77 9.1.5 Histological Findings of Isthmus 79 9.1.6 Clinical Significance and Management 81 Suggested Readings 82 10 Ultrasonic Root End Preparation 83Spyros Floratos and Syngcuk Kim 10.1 Armamentarium 83 Suggested Readings 89 11 MTA and Bioceramic Root End Filling Materials 91Sujung Shin, Ian Chen, Bekir Karabucak, SeungHo Baek, and Syngcuk Kim 11.1 Mineral Trioxide Aggregate (MTA) 92 11.1.1 Advantages of MTA 92 11.1.1.1 Sealing Ability 92 11.1.1.2 Biocompatibility and Bioactivity 92 11.1.2 Drawbacks of MTA 93 11.2 Bioceramics 93 11.3 MTA and Bioceramic Application During Apicoectomy 95 11.4 Other Types of Cements for Root End Filling 96 11.4.1 Intermediate Restorative Material (IRM) 97 11.4.2 Super Ethoxybenzoic Acid (SuperEBA) 97 11.4.3 Geristore and Retroplast 98 11.4.4 New Types of Cements for Root End Filling 98 Suggested Readings 98 12 Flap Reposition and Suturing 101Francesco Maggiore and Meetu Kohli 12.1 Suture Removal 101 Suggested Readings 111 13 PeriapicalWound Healing 113Ingrida Dapkute, Georges Bandelac, Chafic Safi, and Frank Setzer 13.1 Principles ofWound Healing 113 13.2 Healing after Apical Microsurgery 113 13.3 Incomplete Healing/Scar Formation 113 13.4 Evaluation of Healing after Apical Surgery 114 13.5 Healing Evaluation Using CBCT 115 Suggested Readings 118 14 Cone Beam Computed Tomography 119Garrett Guess, Fouad Al-Malki,Meetu Kohli, Bekir Karabucak, and Samuel Kratchman 14.1 How CBCT Works 120 14.2 Indications and Clinical Applications 120 Suggested Readings 142 15 Mental Nerve Management 143Paula Mendez-Montalvo, Fouad Al-Malki, and Syngcuk Kim 15.1 Armamentarium 143 15.1.1 Mental Foramen and Nerve 143 15.1.1.1 Location 143 15.1.1.2 Anterior Loop 143 15.1.1.3 Number of Mental Foramina 144 15.1.2 Mental Foramen Detection on Radiographs 144 15.1.2.1 Periapical Radiograph 144 15.1.2.2 Panoramic Films 145 15.1.2.3 Cone Beam Computed Tomography (CBCT) 145 15.1.3 Neurosensory Alteration 145 15.1.3.1 Surgical Technique to Avoid Iatrogenic Mental Nerve Trauma and Injury 146 15.1.4 Groove Technique Using Piezoelectric Surgery 146 Suggested Readings 150 16 Maxillary Posterior Surgery, the Sinus, andManaging Palatal Access 151Garrett Guess and Samuel Kratchman 16.1 Maxillary Premolars 151 16.1.1 Access 151 16.1.2 Instrumentation 151 16.2 Sinus Exposure 151 16.3 Maxillary First Molars 153 16.3.1 Access 153 16.3.2 Palatal Approach 155 16.4 Second Molars 159 16.4.1 Periodontal Aspects 161 Suggested Readings 162 17 Surgical Root Perforation Repair 163Raed Kasem, Samuel Kratchman, and Meetu Kohli 17.1 Possible Challenges to Non-surgical Perforation Repair 163 17.2 Factors that Enhance Positive Long-Term Prognosis for Perforation Repair 164 17.3 Surgical Perforation Repair Techniques 166 17.4 Surgical Treatment for External Root Resorption 168 Suggested Readings 177 18 Intentional Replantation 179David Li and Samuel Kratchman 18.1 Armamentarium 179 18.1.1 Success Rate 179 18.1.2 Indications 179 18.1.3 Replantation or Apicoectomy 179 18.1.4 Extraction 182 18.1.5 Extraoral Phase 183 18.1.6 Storage Medium 183 18.1.7 Replantation 183 18.1.8 Splinting 185 18.1.9 Postop Instructions 186 18.1.10 Cone Beam CT Scan 186 18.1.11 Repairing Procedural Mishaps 186 Suggested Readings 191 19 Guided Tissue Regeneration in Endodontic Microsurgery 193Garrett Guess and Samuel Kratchman Suggested Readings 202 20 Implants versus Endodontic Microsurgery 205Frank Setzer and Syngcuk Kim 20.1 Historical Perspective 205 20.2 Benefits of Implants 205 20.3 Long-Term Prognosis of Dental Implants 205 20.4 Implant Complications 206 20.5 Long-Term Prognosis of Endodontically Treated Teeth with Root End Surgery 207 20.6 Conclusion 209 Suggested Readings 210 21 Prognosis of Endodontic Microsurgery 213Meetu Kohli and Euiseong Kim 21.1 Best Available Evidence 213 21.2 Parameters for Success: Clinical and Radiographic 2D 214 21.3 Parameters for Success: "Penn 3D Criteria" for Assessing Healing on CBCT 215 21.4 Reversal of Success 215 21.5 TraditionalMethods 217 21.6 Modern Technique versus the Complete Microsurgical Approach 218 21.7 Root End Filling Materials 218 21.8 Case Selection 219 21.9 Resurgery 219 21.10 Summary 219 Suggested Readings 219 22 Positioning 221Samuel Kratchman and Syngcuk Kim 22.1 Armamentarium 221 Suggested Readings 226 Index 227