I clinical report _ apical microsurgery series Apical microsurgery— Part III: Access and crypt management Author_ Dr John J. Stropko, USA In Parts I and II of this series, we discussed the preparation of the patient, the incision, and atraumatic flap elevation. These are the first three steps necessary to perform predictable apical microsurgery. As was mentioned, it is of utmost importance that each step is completed before proceeding to the next step. If a step is omitted or not completed, the next step will be difficult, if not impossible, to complete properly. The operation will develop into a stressful experience for the patient, the staff, and the doctor, with a less desirable or predictable end result. If all of the steps are completed as outlined, all procedures can be performed without stress and a favourable post-operative result is predictable. I have completed hundreds of apical microsurgical operations and the desirable results were mainly the same with just a few exceptions. The technique is very gentle and predictable—if all of the steps are followed without compromise! 2) How much of the apex can be bevelled, or resected? Usually, there is an adequate amount of root length to work with. The shorter the root, the more conservative the operator will have to be when bevelling, and the closer the bevel should be to 0°, so less removal of the root end is possible. If an exceptionally long post is present, that is closer to the apical terminus than desired, not as much of the root end can be resected. Or, if the periodontal bone level is less than desired, a more conservative amount of apical root structure should be removed to preserve as much of the crown/root ratio as possible. Fig. 1 Fig. 1_An adequate amount of crestal bone should remain between the osseous crest and the coronal extent of the crypt. _After the properly designed flap has been atraumatically reflected and retracted, the access preparation is ready. Some important considerations are: 1) How much bone exists on the buccal aspect of the root being surgerised? If there is total dehiscence, guided tissue regeneration has to be considered. Ideally, there should be at least 3 to 4 mm of healthy, intact crestal buccal bone remaining after the access preparation has been completed (Fig. 1). Fortunately, the Operating Microscope (OM), and/or the Endoscope, allows the operator the luxury of being ultra-conservative when necessary. The access to the root end is achieved most effectively with a high-speed handpiece that has no air exiting the working end (Fig. 2a). The usual air-driven handpiece does have air at the working end and using it may result in an air embolism. It is important to use as much water coolant as vision will permit to maintain the moisture in the tissues. Using a fine stream of water from the Stropko Irrigator fitted with a 27-gauge needle, the scope 18 I roots 4_ 2009