Endodontic microsurgery is a predictable treatment option when orthograde treatment or retreatment is unsuccessful or unfeasible. However, when there is a gross compromise of periapical bone, achievement of bone regeneration after the surgical procedure may be hampered. In such cases, the application of guided tissue regeneration principles, with adjunctive use of leukocyte platelet-rich fibrin to fill the bone defect as a bone substitute and as a membrane to cover the site, provides a cost-effective solution with the benefits of accelerated physiological healing and reduced post-surgical pain and discomfort. This case report presents 2 cases of endodontic microsurgery of the upper lateral incisors with loss of buccal cortical plate, where platelet-rich fibrin was successfully applied.

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• Focuses and Trends of Research on Platelet-Rich Fibrin: A Bibliometric and Visual Analysis
  Ying Zhao, Chen Dong, Liumeizi Fan, Ting Lei, Xin Ge, Zhou Yu, Sheng Hu
  Indian Journal of Plastic Surgery.2024; 57(05): 356.     CrossRef

Apical surgery for a mandibular molar is still challenging for many reasons. This report describes the applications of computer-guided cortical ‘bone-window technique’ using piezoelectric saws that prevented any nerve damage in performing endodontic microsurgery of a mandibular molar. A 49-year-old woman presented with gumboil on tooth #36 (previously endodontically treated tooth) and was diagnosed with chronic apical abscess. Periapical lesions were confirmed using cone-beam computed tomography (CBCT). Endodontic microsurgery for the mesial and distal roots of tooth #36 was planned. Following the transfer of data of the CBCT images and the scanned cast to an implant surgical planning program, data from both devices were merged. A surgical stent was designed, on the superimposed three-dimensional model, to guide the preparation of a cortical window on the buccal side of tooth #36. Endodontic microsurgery was performed with a printed surgical template. Minimal osteotomy was required and preservation of the buccal cortical plate rendered this endodontic surgery less traumatic. No postoperative complications such as mental nerve damage were reported. Window technique guided by a computer-aided design/computer-aided manufacture based surgical template can be considerably useful in endodontic microsurgery in complicated cases.

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• Accuracy of Guided Dual Technique in Esthetic Crown Lengthening: A Prospective Case‐Series Study
  Meritxell Enfedaque‐Prat, Albert González‐Barnadas, Adrià Jorba‐García, Javi Vilarrasa, Jorge Toledano‐Serrabona, Rui Figueiredo, Eduard Valmaseda‐Castellón, Octavi Camps‐Font
  Journal of Esthetic and Restorative Dentistry.2025;[Epub]     CrossRef
• Endodontic Microsurgery of a Mandibular Molar Using a Dynamic Navigation System (DNS) and Cortical Window Technique: A Case Report
  Gustavo Castillo, Silvia Restrepo-Méndez, Oscar Zuluaga, Paola Escobar-Villegas
  Journal of Endodontic Microsurgery.2024; 3: 1.     CrossRef
• The bone lid technique in endodontic microsurgery
  Min Zhang, He Liu, Ya Shen
  Asian Journal of Surgery.2024; 47(7): 3126.     CrossRef
• Guided Periradicular Surgery with Er,Cr:YSGG Laser Osteotomy: A Case Report
  Julian Torres Celeita, Johanna Hernández la Rotta, Amdie Chirinos Salazar, Jorge Fandiño Rodríguez, Laura López Rincón, Mauren Orduz Solorzano, Diana Parra Galvis, Oscar Jiménez Peña
  Journal of Endodontic Microsurgery.2024;[Epub]     CrossRef
• Piezoelectric Endodontic Microsurgery with Modified Cortical Window Technique: A Case Report
  Rafael Fernández-Grisales, Wilder Rojas, Carolina Berruecos-Orozco
  Journal of Endodontic Microsurgery.2023; 2: 34.     CrossRef
• The Impact of the Preferred Reporting Items for Case Reports in Endodontics (PRICE) 2020 Guidelines on the Reporting of Endodontic Case Reports
  Sofian Youssef, Phillip Tomson, Amir Reza Akbari, Natalie Archer, Fayjel Shah, Jasmeet Heran, Sunmeet Kandhari, Sandeep Pai, Shivakar Mehrotra, Joanna M Batt
  Cureus.2023;[Epub]     CrossRef
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  Chen Chen, Rui Zhang, Wei Zhang, Fangzhe Li, Zan Wang, Li Qin, Yun Chen, Zhuan Bian, Liuyan Meng
  Clinical Oral Investigations.2023; 27(9): 5317.     CrossRef
• New-designed 3D printed surgical guide promotes the accuracy of endodontic microsurgery: a study of 14 upper anterior teeth
  Dan Zhao, Weige Xie, Tianguo Li, Anqi Wang, Li Wu, Wen Kang, Lu Wang, Shiliang Guo, Xuna Tang, Sijing Xie
  Scientific Reports.2023;[Epub]     CrossRef
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• Piezoelectric Device and Dynamic Navigation System Integration for Bone Window-Guided Surgery
  Frederico C. Martinho, Ina L. Griffin, Patricia A. Tordik
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• Bone Window Technique in Endodontic Microsurgery – Report of Two Cases
  Spyros Floratos, Vasileios Molonis, Apostolos Tsolakis, Stylianos Kykalos, Konstantinos Kontzoglou
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  Sun Mi Jang, Euiseong Kim, Kyung-San Min
  Medicina.2021; 57(3): 270.     CrossRef

Although it is challenging, the early diagnosis of a vertical root fracture (VRF) is crucial in order to ensure tooth preservation. The purpose of this clinical case report was to describe reparative surgery performed to treat a tooth affected by an incomplete VRF. A 26 year old male patient was suspected to have a VRF in a maxillary left central incisor, and an exploratory flap was performed in order to confirm the diagnosis. After detecting the fracture, the lesion was surgically treated, the fracture and the infected root-end were removed, and a platelet-rich plasma membrane was used to cover the defect in order to prevent bacterial migration. A 24 month clinical and radiological follow-up examination showed that the tooth was asymptomatic and that the healing process was in progress. The surgical approach described here may be considered an effective treatment for a combined endodontic-periodontal lesion originating from an incomplete VRF and a recurrent periapical lesion.

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• Biomechanical perspectives on dentine cracks and fractures: Implications in their clinical management
  Sishi Chen, Dwayne Arola, Domenico Ricucci, Brian E. Bergeron, John A. Branton, Li-sha Gu, Franklin R. Tay
  Journal of Dentistry.2023; 130: 104424.     CrossRef
• Efficacy of Autologous Platelet Concentrates in Regenerative Endodontic Treatment: A Systematic Review of Human Studies
  Joanna Metlerska, Irini Fagogeni, Alicja Nowicka
  Journal of Endodontics.2019; 45(1): 20.     CrossRef
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  Eyal Rosen, Ilan Beitlitum, Igor Tsesis
  Evidence-Based Endodontics.2018;[Epub]     CrossRef

Appropriate use of local hemostatic agent is one of the important factors on the prognosis of endodontic microsurgery. However, most investigations to date focus on the hemostatic efficacy of the agents, whereas their biologic characteristics have not received enough attention. The purpose of this paper was to review the biologic response of local hemostatic agents, and to provide clinical guidelines on their use during endodontic microsurgery. Electronic database (PUBMED) was screened to search related studies from 1980 to 2013, and 8 clinical studies and 18 animal studies were identified. Among the materials used in these studies, most widely-investigated and used materials, epinephrine, ferric sulfate (FS) and calcium sulfate (CS), were thoroughly discussed. Influence of these materials on local tissue and systemic condition, such as inflammatory and foreign body reaction, local ischemia, dyspigmentation, delayed or enhanced bone and soft tissue healing, and potential cardiovascular complications were assessed. Additionally, biological property of their carrier materials, cotton pellet and absorbable collagen, were also discussed. Clinicians should be aware of the biologic properties of local hemostatic agents and their carrier materials, and should pay attention to the potential complications when using them in endodontic microsurgery.

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• Expert consensus on apical microsurgery
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  ACS Applied Bio Materials.2022; 5(4): 1501.     CrossRef
• COMPARING THE CLINICAL AND RADIOGRAPHIC OUTCOMES OF PULPOTOMIES IN PRIMARY MOLARS USING BIOACTIVE ENDODONTIC MATERIALS AND FERRIC SULFATE – A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CLINICAL TRIALS
  VELLORE KANNAN GOPINATH, SHAJU JACOB PULIKKOTIL, SAJESH K VEETTIL, LALLI DHARMARAJAN, PONNUDURAI SAMUEL GNANA PRAKASH, VINEET DHAR, JAYAKUMAR JAYARAMAN
  Journal of Evidence-Based Dental Practice.2022; 22(4): 101770.     CrossRef
• Perioperative Antiplatelet and Anticoagulant Management with Endodontic Microsurgical Techniques
  Anita Aminoshariae, Mark Donaldson, Michael Horan, James C. Kulild, Dale Baur
  Journal of Endodontics.2021; 47(10): 1557.     CrossRef
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  Shanthana Reddy, Ramya Shenoy, LohithReddy Mandadi, Ishani Saluja, ManuelS Thomas
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Epinephrine is one of the most widely-used vasoconstrictors in dental treatment including endodontic microsurgery. However, the systemic safety of epinephrine has been in debate for many years because of its potential risk to cause cardiovascular complications. The purpose of this review was to assess the cardiovascular effect of epinephrine use in endodontic microsurgery. Endodontic microsurgery directly applies epinephrine into the bone cavity, and the amount is reported to be much larger than other dental surgeries. Moreover, when considering that systemic potency of intraosseous application is reported to be comparable to intravenous application, the systemic influence of epinephrine could be increased in endodontic microsurgery. Besides, pre-existing cardiovascular complications or drug interactions can enhance its systemic influence, resulting in increased susceptibility to cardiovascular complications. Although clinical studies have not reported significant complications for patients without severe systemic complications, many epinephrine-induced emergency cases are warning the cardiovascular risk related with pre-existing systemic disease or drug interactions. Epinephrine is a dose-sensitive drug, and its hypersensitivity reaction can be fatal to patients when it is related to cardiovascular complications. Therefore, clinicians should recognize the risk, and the usage of pre-operative patient evaluation, dose control and patient monitoring are required to ensure patient's safety during endodontic microsurgery.

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• Expert consensus on apical microsurgery
  Hanguo Wang, Xin Xu, Zhuan Bian, Jingping Liang, Zhi Chen, Benxiang Hou, Lihong Qiu, Wenxia Chen, Xi Wei, Kaijin Hu, Qintao Wang, Zuhua Wang, Jiyao Li, Dingming Huang, Xiaoyan Wang, Zhengwei Huang, Liuyan Meng, Chen Zhang, Fangfang Xie, Di Yang, Jinhua Yu
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• Hemostatic agents in periapical surgery: The systematic review
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  Jeong Soo Lee, Sung Hee Hyun, Ji-Sook Lee, In Sik Kim
  Korean Journal of Clinical Laboratory Science.2014; 46(1): 22.     CrossRef
• Biologic response of local hemostatic agents used in endodontic microsurgery
  Youngjune Jang, Hyeon Kim, Byoung-Duck Roh, Euiseong Kim
  Restorative Dentistry & Endodontics.2014; 39(2): 79.     CrossRef

Nowadays, oral anticoagulants are commonly prescribed to numerous patients for preventing cardiovascular accident such as thromboembolism. An important side effect of anticoagulant is anti-hemostasis. In a major surgery, the oral anticoagulant therapy (OAT) regimen must be changed before the surgery for proper post-operative bleeding control. However, in a minor dental surgery and endodontic surgery, the necessity for changing or discontinuing the OAT is open to debate. In this study, risks of the consequences were weighed and analyzed. In patients who stop the OAT, the occurrence of thromboembolic complication is rare but the result is fatal. In patients who continuing the OAT, post-operative bleeding can be controlled well with the local hemostatic measures. In the endodontic surgery, there are almost no studies about this issue. The intra-operative bleeding control is particularly important in the endodontic surgery because of its delicate and sensitive procedures such as inspection of resected root surface using dental microscope and retrograde filling. Further studies are necessary about this issue in the viewpoint of endodontic surgery.

Citations

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• Expert consensus on apical microsurgery
  Hanguo Wang, Xin Xu, Zhuan Bian, Jingping Liang, Zhi Chen, Benxiang Hou, Lihong Qiu, Wenxia Chen, Xi Wei, Kaijin Hu, Qintao Wang, Zuhua Wang, Jiyao Li, Dingming Huang, Xiaoyan Wang, Zhengwei Huang, Liuyan Meng, Chen Zhang, Fangfang Xie, Di Yang, Jinhua Yu
  International Journal of Oral Science.2025;[Epub]     CrossRef
• Management of Patients Receiving Anticoagulation Therapy in Dental Practice: A Systematic Review
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• Hemostatic Alginate/Nano-Hydroxyapatite Composite Aerogel Loaded with Tranexamic Acid for the Potential Protection against Alveolar Osteitis
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• Perioperative Antiplatelet and Anticoagulant Management with Endodontic Microsurgical Techniques
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  Journal of Endodontics.2021; 47(10): 1557.     CrossRef
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• Biologic response of local hemostatic agents used in endodontic microsurgery
  Youngjune Jang, Hyeon Kim, Byoung-Duck Roh, Euiseong Kim
  Restorative Dentistry & Endodontics.2014; 39(2): 79.     CrossRef
• Cardiovascular effect of epinephrine in endodontic microsurgery: a review
  Youngjune Jang, Euiseong Kim
  Restorative Dentistry & Endodontics.2013; 38(4): 187.     CrossRef

Apical surgery cuts off the apical root and the crown-to-root ratio becomes unfavorable. Crown-to-root ratio has been applied to periodontally compromised teeth. Apical root resection is a different matter from periodontal bone loss. The purpose of this paper is to review the validity of crown-to-root ratio in the apically resected teeth. Most roots have conical shape and the root surface area of coronal part is wider than apical part of the same length. Therefore loss of alveolar bone support from apical resection is much less than its linear length.The maximum stress from mastication concentrates on the cervical area and the minimum stress was found on the apical 1/3 area. Therefore apical root resection is not so harmful as periodontal bone loss. Osteotomy for apical resection reduces longitudinal width of the buccal bone and increases the risk of endo-perio communication which leads to failure. Endodontic microsurgery is able to realize 0 degree or shallow bevel and precise length of root resection, and minimize the longitudinal width of osteotomy. The crown-to-root ratio is not valid in evaluating the prosthodontic prognosis of the apically resected teeth. Accurate execution of endodontic microsurgery to preserve the buccal bone is essential to avoid endo-perio communication.

Citations

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• Expert consensus on apical microsurgery
  Hanguo Wang, Xin Xu, Zhuan Bian, Jingping Liang, Zhi Chen, Benxiang Hou, Lihong Qiu, Wenxia Chen, Xi Wei, Kaijin Hu, Qintao Wang, Zuhua Wang, Jiyao Li, Dingming Huang, Xiaoyan Wang, Zhengwei Huang, Liuyan Meng, Chen Zhang, Fangfang Xie, Di Yang, Jinhua Yu
  International Journal of Oral Science.2025;[Epub]     CrossRef
• Coexistence of horizontal bone loss and dehiscence with the bundle and conventional fiber post: a finite element analysis
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  Computer Methods in Biomechanics and Biomedical Engineering.2024; : 1.     CrossRef
• The tooth survival of non‐surgical root‐filled posterior teeth and the associated prognostic tooth‐related factors: A systematic review and meta‐analysis
  S. R. Patel, F. Jarad, E. Moawad, A. Boland, J. Greenhalgh, Maria Liu, Michelle Maden
  International Endodontic Journal.2024; 57(10): 1404.     CrossRef
• New-designed 3D printed surgical guide promotes the accuracy of endodontic microsurgery: a study of 14 upper anterior teeth
  Dan Zhao, Weige Xie, Tianguo Li, Anqi Wang, Li Wu, Wen Kang, Lu Wang, Shiliang Guo, Xuna Tang, Sijing Xie
  Scientific Reports.2023;[Epub]     CrossRef
• Multifactorial Analysis of Endodontic Microsurgery Using Finite Element Models
  Raphael Richert, Jean-Christophe Farges, Jean-Christophe Maurin, Jérôme Molimard, Philippe Boisse, Maxime Ducret
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• Mid‐term outcomes and periodontal prognostic factors of autotransplanted third molars: A retrospective cohort study
  Ernest Lucas‐Taulé, Marc Llaquet, Jesús Muñoz‐Peñalver, José Nart, Federico Hernández‐Alfaro, Jordi Gargallo‐Albiol
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• Effect of length of apical root resection on the biomechanical response of a maxillary central incisor in various occlusal relationships
  S. J. Ran, X. Yang, Z. Sun, Y. Zhang, J. X. Chen, D. M. Wang, B. Liu
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• Changes of Root Length and Root-to-Crown Ratio after Apical Surgery: An Analysis by Using Cone-beam Computed Tomography
  Thomas von Arx, Simon S. Jensen, Michael M. Bornstein
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• Influence of Apical Root Resection on the Biomechanical Response of a Single-rooted Tooth—Part 2: Apical Root Resection Combined with Periodontal Bone Loss
  Youngjune Jang, Hyoung-Taek Hong, Heoung-Jae Chun, Byoung-Duck Roh
  Journal of Endodontics.2015; 41(3): 412.     CrossRef
• Influence of Apical Root Resection on the Biomechanical Response of a Single-rooted Tooth: A 3-dimensional Finite Element Analysis
  Youngjune Jang, Hyoung-Taek Hong, Byoung-Duck Roh, Heoung-Jae Chun
  Journal of Endodontics.2014; 40(9): 1489.     CrossRef

In current endodontic practice, introduction of operating microscope, ultrasonic instruments, and microinstruments has induced a big change in the field of surgical retreatment. In this study, we aimed to offer key steps of endodontic microsurgery procedure compared with traditional root-end surgery, and to evaluate factors influencing success and failure based on published articles.

Endodontic microsurgery is a surgical procedure performed with the aid of a microscope, ultrasonic instruments and modern microsurgical instruments. The microscope provides magnification and illumination - essential for identifying minute details of the apical anatomy. Ultrasonic instruments facilitate the precise root-end preparation that is within the anatomical space of the canal. Modern endodontics can therefore be performed with precision and predictability, thus eliminating the disadvantages inherent in traditional periapical surgery such as large osteotomy, beveled apicoectomy, inaccurate root-end preparation and the inability to observe isthmus.

Factors influencing the outcomes of endodontic microsurgery may be diverse, but standardization of procedures can minimize its range. Among patient and tooth-related factors, periodontal status and tooth position are known to be prognostic, but there are only few articles concerning this matter. High-evidence randomized clinical trials or prospective cohort studies are needed to confirm these findings.

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• Treatment-Related Factors Affecting the Success of Endodontic Microsurgery and the Influence of GTR on Radiographic Healing—A Cone-Beam Computed Tomography Study
  Daniel Bieszczad, Jarosław Wichlinski, Tomasz Kaczmarzyk
  Journal of Clinical Medicine.2023; 12(19): 6382.     CrossRef
• Factors Affecting the Success of Endodontic Microsurgery: A Cone-Beam Computed Tomography Study
  Daniel Bieszczad, Jaroslaw Wichlinski, Tomasz Kaczmarzyk
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• The Influence of Bone Tissue Deficiency on the Outcome of Endodontic Microsurgery: A Prospective Study
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• Prognostic Factors of Clinical Outcomes in Endodontic Microsurgery: A Prospective Study
  Minju Song, Sahng Gyoon Kim, Seung-Jong Lee, Baekil Kim, Euiseong Kim
  Journal of Endodontics.2013; 39(12): 1491.     CrossRef
• Is stopping of anticoagulant therapy really required in a minor dental surgery? - How about in an endodontic microsurgery?
  Yong-Wook Cho, Euiseong Kim
  Restorative Dentistry & Endodontics.2013; 38(3): 113.     CrossRef