clinical report _ apical microsurgery series I be kept well within the confines of the crypt. It has an extremely low pH and will instantly chemically cauterise anything it touches! The buccal plate of bone, the periosteum, soft tissue, and the Snyderian membrane should always be avoided! It is important to keep in mind: If a little bit is good, a lot is not better! Use only small amounts on the end of an applicator because a small amount goes a long way (Fig. 4). NOTE: There are two popular forms of ferric sulfate: Monsel’s Solution has a concentration of 72 % and Cutrol has one of 53 %. I like Monsel’s Solution because it is very effective, readily available and less costly to use. On a few occasions, severe haemorrhaging occurs. This can be a result of inflammation, a severed interdental artery or a compromised clotting mechanism. At any rate, when the blood flows faster than the evacuator can remove it, there is good reason for a little excitement and fast action! Immediately, pressure must be applied over the crypt with a finger. This will stop the haemorrhaging long enough to prepare the next few steps calmly. First, in a low and controlled voice, instruct the scope assistant to insert a bigger tip into the evacuator and hold it close to the crypt. If after removing your finger the haemorrhaging has not subsided, quickly replace your finger over the crypt as before. It is a good idea to take a radiograph and clinically re-evaluate the surgical area at this time to ensure no unforeseen anatomical structures (mandibular canal, palatine artery, etc.) have been infringed upon. Now it is safe to have your surgical assistant make a ‘cotton plug’ with a piece of sterile cotton roll large enough to completely fill the crypt, lightly streaking the tissue surface with Monsel’s Solution and insert into the crypt, holding it firmly in place with your finger for a minute or so. After a few minutes, the cotton plug can be safely removed and you can proceed without undue concern. A gentle irrigation with the Stropko Irrigator will remove most of the dark-coloured coagulum. The above technique has worked all three times I found myself in this situation. In two of the cases, an interdental artery was the cause and the other was highly inflamed granulation tissue remaining in the crypt. If haemorrhaging occurs on the surface of the exposed buccal plate, a Touch ’n Heat (SybronEndo) can be used. The scope assistant can evacuate the bleeder with a small surgical tip, so its exact source can be determined, and the Touch ’n Heat can be used to effectively cauterise it. After the haemorrhaging has been completely controlled and the crypt relatively cleansed of the coagulum, a fresh piece of Telfa Pad should be placed over the internal surface of the crypt (Fig. 6). Keep in mind when using the OM that light and dryness are the most important factors for good visibility. NOTE: Never proceed to the next step until total crypt management has been accomplished. Once the crypt management is completed, the doctor can proceed to refinement of the bevel and preparing the retropreps with confidence and good visibility. At the end of this step, all haemorrhaging should be controlled, the grossly resected apical end of the root should be easily seen and the floor of the crypt should be covered with a clean, white piece of Telfa Pad; an apical microsurgeon’s dream!_ _Reference 1. Lemon R, Steel P, Jeansonne B. Ferric Sulfate Hemostasis: Effect on Osseous Wound Healing: Left in situ for Maximum Exposure. J Endod 1993: 170–173. _about the author roots Dr John J. Stropko received his DDS from Indiana University in 1964 and for 24 years practised restorative dentistry. In 1989, he received a certificate for endodontics from Boston University. He recently retired from the private practice of endodontics in Scottsdale in Arizona. Dr Stropko is an internationally recognised authority on micro-endodontics. He has been a visiting clinical instructor at the Pacific Endodontic Research Foundation (PERF), an Adjunct Assistant Professor at Boston University and an Assistant Professor of graduate Clinical Endodontics at Loma Linda University. His research on in vivo root canal morphology has been published in the Journal of Endodontics. He is the inventor of the Stropko Irrigator, has published in several journals and textbooks, and is an internationally known speaker. Dr Stropko has performed numerous live micro-endodontic and microsurgical demonstrations. He is the co-founder of Clinical Endodontic Seminars. He can be contacted at topendo@aol.com. roots 4 _ 2009 I 21