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I 33 case report _ peri-apical microsurgery I roots2_2010 A full thickness flap was made with a semilunar incision. Selection of this type of incision was de- termined by the absence of a large, radiographically visible bone defect (Fig. 2) and for aesthetic reasons. This type of incision does not carry the risk of post- operative gingival recession. After raising the surgical flap, it was possible to note the integrity of the cortical vestibular bone. The osteotomy was performed using surgical piezo- electric ultrasound and CVDentus W1-0 insert for more precise control of the cut, followed by apicec- tomy, also performed using ultrasound. _The benefits of ultrasound There are technical and biological advantages to osteotomy performed using ultrasound when compared to the use of high or low speed burs. Ul- trasoundhasahighlyselectivetissuecuttingability. Its action occurs only on mineralised tissues such as bone and tooth, preserving soft tissues such as nerves, vessels and mucosae. During osteotomy, the amplitude of the micro-movements generated by the ultrasonic insert ranged between 60 and 210µm, making the hard-tissue cut extremely pre- cise.Thisisassociatedwiththeformationofacoustic micro-stream and cavitation in the operative field, which promote a clean field, as observed in Figures 8a to c.13–20 The biological benefits of piezoelectric surgery particularly involve the maintenance of cellular via- bility in the operated region, so that the first post- operative stages of the bone repair process are bet- ter. It induces a faster increase in morphogenetic bone proteins and modulates the inflammatory reaction, in addition to stimulating healing.14 The fractured instrument was removed together with the apical root third in the apicectomy (Fig. 8d). The apical root cut was performed at an angle of 90° to the long axis of the root, in order to expose the smallestquantityofdentinaltubulesandpreservethe most root extension, favouring microbiological con- trol and function of the dental remainder.21 The quality of the remainder of the root filling was evaluated by introducing a micro-mirror into the apical bone recess and reviewing the remainder oftherootfilling,whichwasconsideredsatisfactory because it filled the root canals uniformly (Fig. 8c). This was the criterion that determined whether retro-preparation and retro-filling of the root canals should be performed, since this region of the canal had been adequately cleaned, shaped and filled. The sutures were made with the aid of the operat- ing microscope. Two simple stitches with Vicryl 6-0 thread were made to stabilise the flap, and another continuousstitchwasmadewithVicryl9-0threadto coapt the edges (Fig. 9). Clinical control was performed after 7, 30 and 90 days. There was remission of all the clinical signs and symptoms of endodontic infection._ Editorial note: A list of references is available from the publisher. Fig. 9_Post-op X-ray. Dr Leandro A.P.Pereira isaspecialistinEndodontics andProfessorofEndodontics attheSchoolofDentistryat SãoLeopoldoMandicin CampinasinSãoPauloin Brazil.HelecturestheSpe- cialistEndodonticscourseof theEscolaAperfeiçoamento ProfissionalAssociaçãodosCirurgiõesDentistas deCampinasinCampinas.DrPereirarunshisown privateclinicalinCampinasandcanbecontactedat leandroapp@sedcare.com.brandviahisWebsite www.sedcare.com.br. _about the author roots Fig. 9