clinical report _ apical microsurgery series I Fig. 2a_The surgical handpiece, such as Impact Air, should be used to prevent the possibility of an air embolism. Fig. 2b_Only three surgical burs are normally necessary for the access and REB. Fig. 2 Fig. 3 assistant can keep the area moist and evacuate excess fluids at the same time. The initial access and root end apisection (RER) can be accomplished with just three surgical-length burs: the Lindemann bone bur, a #6 round bur, and an 1,171 fissure bur (Fig. 2b). There are two different ways to begin the access: 1) Estimate the amount of the apex to be resected and with a Lindemann bone-cutting bur, remove the apex and prepare the access opening in one step. If there is any portion of the apex remaining in the crypt, it is curetted out and the access is more or less complete. 2) A more accurate procedure is to estimate the location of the apex. Then, using a #6 surgical length, round bur, slowly and gently remove the bone overlying the buccal surface of the root. Once the buccal surface of the apex has been uncovered, bone is removed until the coronal limit of the crypt is established and the general outline of the apex is readily observed and can be resected at this time. Often, especially with larger peri-apical involvement, the lesion can be curetted and the entire apex exposed. If the lesion is more palatal, or lingual, the root apex may prevent the necessary access for curettage and will have to be partially bevelled, or resected as part of the access process. A thorough curettage is important because it is an important first stage of achieving haemostasis from within the crypt. In general, if all of the granulation tissue is removed, the amount of haemorrhage will be greatly reduced, the management of the crypt will be easier to accomplish, and good visibility will be restored. This technique takes more time but results in improved visibility and the ability to be more precise with the initial RER. The finished bevel will be discussed in more detail later in the article. In general, a biopsy should be performed on all tissue removed from the body. Granted, we are usually quite confident of the pathological diagnosis of the LEO, but my feeling is that even if the odds are 1 in 100,000 that we are correct, no chances should be taken and a biopsy should be taken on a routine basis. The final dimension of the access opening varies and is dependent on several factors: 1) The size and position of the lesion is important. If the lesion is larger, the access will, of necessity, be larger in order to perform a complete curettage. 2) The position of the apex determines the size of the access. The more lingual the apex, the more overlying bone has to be removed and the larger the access has to be for good visibility. 3) The access has to be sufficiently large to allow the instruments room to prepare the apical canal system without inhibiting their freedom of movement. The larger the instruments used, the larger the access must be. 4) The thickness of overlying bone is also important. If the buccal plate is thick, a wider access is necessary to eliminate a ‘tunnel effect’, so vision is not compromised. 5) The experience and ability of the operator, and equipment available is a great determinant of the size the access will need to be. I use both an Endoscope and the OM when performing apical microsurgery. In some cases, the Endoscope (JedMed) permits a better view of the surgical site owing to increased lighting and magnification. It also increases the ability to view previously difficult, and sometimes impossible, areas to be seen with the OM. The extent of a defect or existing anatomical variations that are lingual to the involved root end are typical examples of the value of also having an Endoscope during microsurgical procedures. The management of the crypt is one of the most important steps and the operator should take as roots 4 _ 2009 I 19