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18 I I clinical report _ apical microsurgery series _All steps have been meticulously followed, the root-end fill has been placed, the crypt has re- fillednicely,thefinalradiographhasbeenapproved and it is time to suture the flap into position. Sadly, mostoperatorsnowpushtheoperatingmicroscope (OM) aside and suture without it. Doing so robs the operatorofanopportunitytodemonstratetothem- selves and their patients, the amazing capabilities of the OM. The operator must make a commitment to master the suturing technique using the OM. It will never be accomplished with the OM pushed aside at this critical step in the apical microsurgical procedure.Thefollowingisbasedlargelyonmyown experiencesoverthe12yearsofperforming,teach- ing and writing about apical microsurgery. DrJohnHarrisonhaspublishedsomeofthemost clearlywrittenandcomprehensiveworkonwound- healing associated with peri-apical surgery. There are five publications that are a must read for the endodontic surgeon.1 After reading these, the mi- crosurgical protocol developed by Dr Gary Carr, Dr Richard Rubinstein and others becomes clearer and is more easily understood. Treating the tissues gently and atraumatically is crucial for achieving predictable wound-healing. Oncethesurgicalsiteisreadyforclosure,theflap should be gently massaged to close approximation with the attached tissue. But, keep in mind, the flap has probably lost dimension or shrunk slightly due to the mere act of retraction over a period of time and has endured a slight decrease of blood flow to it. Fortunately, this is usually not a problem. If the initial incision was planned with this final step in mind, the tissues should re-approximate with min- imal manipulation. This is when the operator will appreciatenicescallopingandasharpscalpelwhen making the incision at the beginning of the surgery (Fig. 1). Remember the adage: hindsight is always 20/20. The smooth side of a small #2 mouth mirror can be used to hold the tissue in position, while the second surgical assistant (on the same side of the chairastheoperator)handstheoperatortheneedle Fig. 1_A well planned design of the incision permits gentle and accurate flap re-approximation. Fig. 2_Immediate post-op sutures. Fig. 3_Twenty-four hours post-op, before sutures are removed. Fig. 4_Immediately after suture removal, 24 hours post-op. roots3_2010 Apical microsurgery— Part VI: Sutures, suturing techniques and healing Author_ Dr John J. Stropko, USA Fig. 2 Fig. 3 Fig. 4 Fig. 1