Current Concepts of Periapical Surgery

Attachment of human periodontal ligament fibroblasts to root dentin conditioned with different endodontic irrigants: An experimental study

Background. Periradicular surgery is the last treatment option for teeth with persistent periradicular endodontic lesions. This study aimed to assess the adhesion of fibroblasts to root dentin conditioned with ethylenediaminetetraacetic acid (EDTA), MTAD, and QMix. Methods. Twelve dentin discs were fabricated of 6 human single-rooted teeth. Fibroblasts were isolated from the periodontal ligament (PDL) of a premolar tooth. The teeth were healthy and freshly extracted from the socket. The samples were divided into four groups for surface conditioning with (I) EDTA, (II) MTAD, (III) QMix, and the control group. Fibroblasts were cultured on conditioned dentin discs at 37°C, 95% air, and 5% CO2 for 4 hours and then rinsed with PBS three times to eliminate unattached cells from the surface. The mean counts of attached cells were calculated using a Neubauer chamber. Also, the attachment of fibroblasts was evaluated using scanning electron microscopy (SEM). Results. The mean counts of fibroblasts attached to root dentin in EDTA, QMix, MTAD, and control groups were 303±46, 243±41, 213±33, and 347±38, respectively. No significant difference was noted in the number of fibroblasts attached between MTAD, EDTA, and QMix and the control group (P>0.05). Under SEM, the fibroblasts were flat and spindle-shaped, with cytoplasmic processes covering the untreated dentin surface. In the experimental groups, the cells were rounder with fewer processes. All the three groups showed weaker adhesion to dentin compared to the control (untreated dentin) group. Conclusion. Under the limitations of this study, it was concluded that treating the dentin surface with EDTA, MTAD, or QMIX might not be an effective way to improve the adhesion of human PDL fibroblasts.

Alveolar bone thickness overlying healthy maxillary and mandibular teeth: A systematic review and meta-analysis

OBJECTIVE

To systematically review and meta-analyse the Alveolar Bone Thickness (ABT) overlying healthy teeth. The secondary objective was to review the association of ABT with gender, age, and smoking.

MATERIALS AND METHODS

The PubMed, Embase, Scopus, ProQuest, Web of Science, and Cochrane Library databases were searched up to July 2020. English articles (sample size≥10) which had used CT or CBCT to measure the ABT at clearly defined reference points were included. The maximum likelihood approach meta-analysis was used to estimate the means (95% CIs).

RESULTS

A total of 68 articles were included. The meta-analysis results were as follows: In the anterior maxilla, the mean labial plate thickness ranged from 0.42-1.75mm, while it was thicker for the posterior teeth (0.78-4.31mm). The palatal plate thickness ranged from 0.97-8.13mm. In the anterior mandible, the thickness of labial and lingual plates ranged from 0.4-3.71mm and 0.38-5.44mm, respectively. The alveolar bone was thicker for the posterior teeth both at the labial (0.66-6.31mm) and lingual (2.31-7.77mm) sides. Meta-regression revealed a significant relationship between gender and ABT at several points. There was a controversy regarding the association of ABT with age. No significant difference was evidenced between smokers and non-smokers.

CONCLUSIONS

This study presents a clear image of the alveolar bone structure. Since it has pooled ABT values from various populations, outcomes could be acknowledged as global averages. Therefore, it could provide perspective for several dental procedures, including orthodontic treatments and immediate implant placement.

Effect of full sulcular versus papilla-sparing flap on periodontal parameters in periradicular surgeries: A systematic review and meta-analysis

Background:

Access to apical root canal system is gained after flap elevation using various incision techniques. Soft-tissue healing after periradicular surgery may include gingival recession, papilla recession, changes in probing depth, and clinical attachment loss.

Objective:

The objective of this study was to compare the effect of full sulcular flap design versus papilla-sparing flap design on the periodontal parameters in periradicular surgeries.

Materials and Methods:

It was a systematic review and meta-analysis. Electronic and manual searches were conducted in multiple databases including PubMed, Dental and Oral Sciences, Cochrane, and CINAHL Plus until May 2019. Initial search yielded 2575 studies with 5 articles meeting the inclusion criteria. The primary outcomes assessed were gingival recession and change in the papilla height. The secondary outcomes evaluated were probing depth, clinical attachment loss, postoperative pain, bleeding, and discomfort. Random-effects model was employed for computation of effect size, and forest plots were made.

Results:

Out of the five articles that satisfied the inclusion criteria, three were randomized control trials and two were nonrandom trials. No significant differences were found in the gingival recession (P = 0.79), papilla height (P = 0.55), gingival bleeding, and plaque indices. Statistically significant differences in probing depth (P = 0.006) and clinical attachment loss (P = 0.0004) were observed for the two flap designs in probing depth (P = 0.006) and clinical attachment loss (P = 0.0004).

Conclusions:

The present systematic review and meta-analysis showed that probing depth and attachment loss are affected by the choice of flap design. On the other hand, gingival recession and papilla height are not influenced by the type of incision. However, finding of the present review may change if more studies on this topic will be included in the future. Therefore, more clinical trials with long-term follow-ups are needed.

Nonsurgical endodontic management of mandibular first premolar with incomplete root-end resection

The complexity of the nonsurgical endodontic retreatment should be weighed against the benefit of surgical approach. This case report describes uncommon diagnosis and successful nonsurgical endodontic management of mandibular first premolar with a previous history of failed apicoectomy and incomplete root-end resection using mineral trioxide aggregate and cone-beam computed tomography.

Endodontic Surgery Associated with Guided Tissue Regeneration Technique: Case Report

AbstractNon-surgical endodontic retreatment should always be the first option for reintervention when the initial endodontic treatment fails. The surgical treatment, called periradicular surgery, will be the procedure of choice when there is no success after the conventional endodontic retreatment. The purpose of this article is to describe clinical case of endodontic surgery, associated with guided tissue regeneration (GTR). A male patient, 24 years old, was referred for endodontic surgery on tooth 12 after two unsuccessful endodontic interventions. During the surgery, osteotomy, lesion curettage, apicectomy, retrograde obturation with Mineral Trioxide Aggregate (MTA), and filling of the bone failure with lyophilized bone and reabsorbable collagen membrane were performed. After six months of follow-up, the patient did not present any type of painful symptomatology. The endodontic surgery, associated with a technique of guided tissue regeneration, was efficient to solve this clinical case. Keywords: Endodontics. Apicoectomy. Guided Tissue Regeneration. Resumo O retratamento endodôntico não cirúrgico deve sempre ser a primeira opção de reintervenção quando o tratamento endodôntico inicial falha. Já o tratamento cirúrgico, ou cirurgia parendodôntica, será o procedimento de escolha quando não há sucesso após o retratamento endodôntico convencional. O objetivo deste artigo é descrever um caso clínico de cirurgia parendodôntica, associada à regeneração tecidual guiada (RTG). O paciente, gênero masculino, 24 anos, foi encaminhado para cirurgia parendodôntica no dente 12 após duas intervenções endodônticas sem sucesso. Durante a cirurgia foram realizadas manobras de osteotomia, curetagem da lesão, apicectomia, obturação retrógrada com Mineral Trióxido Agregado (MTA), além de preenchimento da falha óssea com osso liofilizado e membrana de colágeno reabsorvível. Após seis meses de acompanhamento do caso, o paciente não apresentou nenhum tipo de sintomatologia dolorosa. A cirurgia parendodôntica, associada à técnica de regeneração tecidual guiada, foi eficiente para solucionar este caso clínico. Palavras-chave: Endodontia. Apicectomia. Regeneração Tecidual Guiada.

Can forces be applied directly to the root for correction of a palatally displaced central incisor with a dilacerated root?

This case report describes the interdisciplinary treatment of an ectopic horizontally placed maxillary right central incisor with severe root dilaceration. The root was distally angulated and entrapped by the root of the maxillary right lateral incisor. The initial force system was aimed at an occlusal displacement and applied to the crown. During the second phase, a button was cemented onto the apex of the impacted tooth. A force from the apex to a temporary anchorage device in the palate moved the root toward the midline. Finally, a root canal and an apectomy were performed and the central incisor could be moved to its ideal position. The treatment generated a normal height of the alveolar bone and an ideal occlusion with a healthy periodontium.

A decision analysis for periapical surgery: Retrospective Study

Background

Periapical surgery is now a reliable therapeutic procedure for the treatment of teeth with periapical lesions, particularly when orthograde retreatment is problematic. However, little information is available regarding treatment planning of cases referred for periapical surgery. Therefore, this study was conducted to analyze and evaluate the factors that affect the decision-making process for periapical surgery.

Material and Methods

This study retrospectively assessed clinical and radiographic data from patients undergoing periapical surgery. The factors involved in deciding to perform periapical surgery were classified into technical, biological, and combined factors.

Results

Out of 821 patients, 544 (66.3%) underwent endodontic treatment/retreatment, 204 (24.8%) were treated with coronal restorations and 60 (7.3%) were treated with post. Periapical surgery was indicated for biological reasons in 35% of patients and for technical reasons in 17.9%. The common biological factor was persistent clinical symptoms (19.7%). The most common technical cause was failure of previous endodontic treatment (66.3%). Nearly half of all periapical lesions (45%) were <5 mm in size. Periapical surgery was justified in only 434 (52.9%) subjects.

Conclusions

We suggest that it is very important for patients to be informed and encouraged about endodontic retreatment in order to reduce unnecessary surgical procedures.

Key words:Periapical surgery, case selection, treatment planning.