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22 I I clinical report _ apical microsurgery series For a denser and stronger consistency, the assis- tantcantouchthenon-workingendofthepluggeror explorer with an ultrasonic tip during the condensa- tionprocess.Theflowisincreasedandamuchdenser fill is achieved. As a result, ultrasonic densification also increases the radiodensity of MTA’s appearance in the post-operative radiograph, but it is still similar to gutta-percha (Fig. 1c). MTA has approximately an hour of working time, which is more than ade- quate for apical microsurgery and reduces the time pressureofthesurgicalprocedure.FinishingtheMTA issimplyamatterofcarvingawaytheexcessmaterial to the level of the resected root-end (Fig. 3a). The moisturenecessaryforthefinalsetisderivedfromthe blood, which fills the crypt after surgery. MTA is very hydrophilicanddependsonmoistureforthefinalset, soitisimperativethatsufficientbleedingisre-estab- lished after crypt management in order to ensure thatthecryptisfilled(Fig.3b).Ifanymaterial,suchas ferricsulphate,hasbeenusedforcryptmanagement, it must be judiciously removed in order to restore blood supply to the crypt. This can be considered the final step in crypt management, and is especially important when MTA is used for the REF. IfthesizeofthelesionindicatestheuseofGuided Bone Regeneration (GBR), good blood supply is indicatedanyway,soallowthebloodtocovertheMTA before placing the GBR material of choice. In a large lesion, it is sometimes difficult, even after curettage, to restore bleeding into the crypt (perhaps the crypt management was a little too effective) and it may be necessary to use a small round bur in the surgical handpiece to make several small holes in the surface of the crypt to aid in the re-establishment of the desired flow of blood. Based on current studies, the operator can select any one of the above-mentioned REF materials and be comfortable that, if the proper protocol has been followed, the apical seal will be predictable and heal- ing uneventful. The final part of this series, published in roots 3/2010, will discuss Sutures,suturingtechniquesand healing (Part VI)._ Editorial note: A complete list of references is available fromthepublisher. roots2_2010 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 inArizona.Dr Stropko is an internationally recognised authority on micro-endodontics. He has been a visiting clinical instructor at the Pacific Endodontic Research Foundation (PERF),anAdjunct Assistant Professor at Boston University and anAssistant 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_about the author Fig. 3a Fig. 3b Fig. 3a_Once placed, the MTA should be carved level with the surface of the REB. Fig. 3b_MTA is hydrophilic so it is important to re-establish the blood supply to cover it after placement.