Endodontic therapy using magnification devices: A systematic review

The impact of bone grafting with/without barrier membrane placement on the outcome of apical surgery: A systematic review and meta-analysis

BACKGROUND

Regenerative techniques are increasingly being advocated in endodontic apical surgery (AS) to enhance the healing of periapical lesions. Various grafting and membrane materials are employed as adjuncts to modern AS.

OBJECTIVES

This systematic review aimed to answer the following PICO question: In patients with apical periodontitis (P) what is the impact of bone grafting with/without barrier membrane materials (I) compared with surgery without grafting materials (C) on the outcome of AS evaluated clinically and radiographically (O).

METHODS

A systematic search was conducted in four databases (Embase, Web of Science, PubMed and Cochrane Central Register of Controlled Trials) until 1 August 2023. Google Scholar was also manually searched. Studies with a prospective randomized design were included. Cochrane risk-of-bias (RoB) tool 2.0 assessed bias. Two independent reviewers performed the study selection, data extraction and appraisal of studies. Meta-analysis was performed using R3.5.1 software.

RESULTS

From the identified 2582 studies, eight randomized clinical trials were included for meta-analysis. Two studies had low RoB, while six had some concerns. Analysis revealed significantly better outcomes when surgery involved bone regeneration techniques than conventional surgery (OR = 2.18, 95% CI: 1.32-4.31, p = .004). Subgroup analyses on individual grafts (OR = 0.22, 95% CI: -0.99 to 1.44, p = .720) (OR = -0.09, 95% CI: -1.42 to 1.23, p = .885) and membranes (OR = -1.09, 95% CI: -2.94 to 0.76, p = .247) and their combinations (OR = 0.03, 95% CI: -1.50 to 1.55, p = .970) did not yield any significant results. The type of membrane used did not significantly impact the outcome (OR = -1.09, 95% CI: -2.94 to 0.76, p = .247) nor did altering the combination of graft/membrane.

DISCUSSION

This systematic review examined the effects of bone grafting with/without membrane placement on the outcome of AS. It highlights the potential advantages of regenerative techniques and the need for further research in this area.

CONCLUSIONS

Based on current evidence, bone grafting with/without barrier membrane placement significantly improves healing after AS. Subgroup analysis of resorbable membranes or grafting did not significantly influence the outcome. The combination of membrane and graft was also not significant. Future well-designed, randomized controlled trials in this area are essential before these materials can be recommended for routine use to enhance healing outcomes in AS.

REGISTRATION

PROSPERO (CRD42021255171).

Effects of magnification on restorative dental preparation performance: a scoping review and level of evidence mapping

OBJECTIVE

This scoping review aimed to identify and describe the available evidence on the effect of magnifying devices (loupe or microscope) on the performance of restorative dental preparations.

MATERIALS AND METHODS

This study was conducted according to the PRISMA-ScR guidelines for scoping reviews and registered on the INPLASY database. An electronic search was performed in four databases and Grey literature for articles published until November 2023. Eligibility criteria were determined using the PICOS strategy and comprised studies that evaluated the performance of magnification devices for restorative dental preparations. A bibliographic mapping of the evidence was conducted.

RESULTS

Sixteen studies met the inclusion criteria. Most of the studies (n = 12) compared the performance of dental preparations using magnification loupes vs. no magnification. The magnification for loupes and microscopes ranged from 2.5x to 4.0x and 6.4x to 10x, respectively. The use of magnifying loupes improved the performance of restorative preparations in 66.6% of the evaluated studies. However, when the magnifications were compared, the greater magnification provided by microscopes did not improve preparation performance compared to magnification loupes. Regarding the place of publication, the American continent concentrates the most significant number of evidence.

CONCLUSIONS

Although evidence for magnification improving the performance of dental preparations has increased over the last decade, basically only in vitro studies (most of which have taken place in the Americas) have been reported in the literature. The evidence suggests that magnification significantly improves restorative preparation performance when compared to non-magnification. However, higher magnifications (e.g., microscopes) do not appear to improve tooth preparation performance compared with lower magnification devices (e.g., magnification loupes).

CLINICAL RELEVANCE

Available evidence supports that using magnification can improve the performance of restored tooth preparations. However, high magnifications have no advantages over lower magnifications.

Comparative Evaluation of the Removal of Gutta Percha From the Root Canal Using Various Retreatment File Systems With and Without Magnification: An In Vitro Study

AIM AND OBJECTIVE

The main goal was to compare the efficacy of gutta percha (GP) removal from the root canal using the Neo Endo Retreatment file system, Solite RS3, and ProTaper Universal Retreatment (PTUR) files with and without magnification under a direct operative microscope using stereomicroscopic evaluation.

MATERIALS AND METHODS

Sixty single-rooted teeth were randomly assigned to one of three groups after obturation till F2 mastercone with resin sealer: Group 1 (n=20): Neo Endo Retreatment Files, Group 2 (n=20): Solite RS3, Group 3 (n=20): PTUR files. Each group was further separated into two subgroups: Subgroup 1: without magnification (no direct operative microscope) and Subgroup 2: with magnification under a direct operative microscope at 12× magnification. After retreatment, the roots were grooved buccolingually and split into two halves using a diamond disc with the help of a chisel. The samples were examined under a stereomicroscope. Images were captured in a digital camera and analyzed using image analyzing software Image Pro v10 (Media Cybernetics).

RESULTS

The Neo Endo retreatment file system had a significantly greater percentage of remaining obturating material than the Solite RS3 Retreatment and PTUR file systems (p<0.05) in both groups with and without magnification. In the group without magnification, Solite RS3 showed a significant difference compared to ProTaper (p<0.05). In the group with magnification, there was no significant difference between the ProTaper Universal retreatment file system and Solite RS3 (p=0.589). Retreatment performed without magnification had more remnant GP when compared to the retreatment procedure performed under magnification of the direct operative microscope.

CONCLUSION

Under stereomicroscopic evaluation, the remnant GP was higher in the Neo Endo File System both with and without magnification than in the Solite Retreatment and PTUR file systems. ProTaper showed moderate significance in removing the obturation than Solite RS3 in the magnification group. The Solite RS3 file system performed as efficiently as the PTUR file system.

Value of including loupes in prosthodontic and endodontic components of dental degrees: a systematic review

Background It is crucial dental students graduate with sound knowledge of endodontics and prosthodontics. The use of loupes is important for these due to their intricate nature, but there is currently no standardisation of curricula.Objective This systematic review investigates the value of including loupes in completing dental degrees and their benefits to dental students.Methods Literature was searched from inception to February 2022 in PubMed, Embase and Scopus. Articles included were primary studies of dental students studying endodontics or prosthodontics, which had outcomes related to the value of utilising loupes in learning, clinical application and ergonomics.Results A total of 1,489 articles were retrieved, of which 14 relevant articles were identified. These articles discussed student perceptions and the impact on visual acuity, ergonomic practices and dental procedures. Overall, students perceived that loupes increased self-confidence and allowed a greater operative view but were initially difficult to use. Using loupes resulted in greater visual acuity than no magnification and improved ergonomic practices by reducing neck angulation and improving posture. Students also received better grades when using loupes during cavity access preparation or root canal therapy.Conclusion The use of loupes by dental students can be beneficial if there is initial teaching on their use.

Analysis of the Accuracy of a Dynamic Navigation System in Endodontic Microsurgery: A Prospective Case Series Study: Accuracy of DNS in EMS

OBJECTIVES

To evaluate the accuracy of a dynamic navigation system (DNS) for guided osteotomy and root-end resection during endodontic microsurgery (EMS) and assess its prognosis.

METHODS

Nine patients who met inclusion criteria underwent DNS-guided EMS. Osteotomy and root-end resection were performed with assistance of DNS (DHC-ENDO1, DCARER Medical Technology, Suzhou, China). The preoperative virtually planned path and postoperative cone-beam computed tomography images were superimposed using DNS software. Accuracy was assessed based on deviations in the platform, apex, and angle of the osteotomy, as well as in the length and angle of the root-end resection. Follow-up evaluations were performed after at least a year postoperatively.

RESULTS

Among the nine patients (11 teeth with 12 roots), the mean platform, apex, and angular deviation of the osteotomy were 1.05 mm, 1.2 mm, and 6.24°, respectively. The mean length and angle deviation of the root-end resection were 0.46 mm and 4.9°, respectively. Significant differences were observed according to tooth position. The platform and apex deviated significantly less in the posterior than in the anterior teeth (p < .05). No significant differences were observed according to arch type, side, and depth of the surgical path (p > .05). Eight patients were evaluated after at least a year postoperatively; clinical and radiographic evaluation revealed a 90% success rate (9/10 teeth).

CONCLUSIONS

This study demonstrated high accuracy of DNS in EMS. Furthermore, DNS-guided EMS had a success rate similar to that of freehand EMS over a short-term follow-up. Further study with a larger sample size is necessary.

CLINICAL SIGNIFICANCE

The present novel DNS technology is a viable method for guided osteotomy and root-end resection in EMS.

CLINICAL TRIAL REGISTRATION NUMBER

ChiCTR2100042312.

Factors that influence the outcomes of surgical endodontic treatment

Surgical endodontic treatment encompasses a broad spectrum of procedures, amongst which root-end cavity preparation and filling, retrograde root canal treatment and through-and-through endodontic surgery, may be classified under the umbrella term 'Root-end surgery'. This narrative review considers the available data on periapical healing, soft tissue healing, tooth survival and oral health-related quality of life (OHRQoL), following root-end surgery and the factors that affect its outcomes. The pooled periapical healed rate for the studies published up to 2021 was 69% (95% CI: 65%, 73%) but increased to 76% (95% CI: 66%, 86%) when only data from the 2020's studies were analysed. The prognostic factors consistently reported for periapical healing have included: pre-operative periapical lesion with complete loss of buccal plate, quality of root-end preparation, remaining thickness of apical root dentine and restorative status. Soft tissue healing of the reflected flap was found to have a positive association with periapical healing. The survival rates following root-end surgery range from 48% to 93%, with failure of periapical healing associated with root and crown fracture, being the predominant reasons for tooth extraction. The factors influencing impact of root-end surgery on patients' quality of life could not be adequately evaluated due to design flaws in the available studies. In conclusion, if root canal treatment failure due to leakage through cracks, fractures or restoration margin are excluded, the remaining cases may represent localized residual infection and inflammation at the periapex that should be amenable to predictable management with the aid of modern root-end surgery.

Prognostic Factors in Endodontic Surgery Using an Endoscope: A 1 Year Retrospective Cohort Study

This retrospective study clarified the success rate of endoscopic endodontic surgeries and identified predictors accounting for successful surgeries. In this retrospective study, 242 patients (90 males, 152 females) who underwent endoscopic endodontic surgery at a single general hospital and were diagnosed through follow-up one year later were included. Risk factors were categorized into attributes, general health, anatomy, and surgery. Then, the correlation coefficient was calculated for the success or failure of endodontic surgery for each variable, the odds ratio was calculated for the upper variable, and factors related to the surgical prognosis factor were identified. The success rate of endodontic surgery was 95.3%, showing that it was a highly predictable treatment. The top three correlation coefficients were post, age, and perilesional sclerotic signs. Among them, the presence of posts was the highest, compared with the odds ratio, which was 9.592. This retrospective study revealed the success rate and risk factors accounting for endoscopic endodontic surgeries. Among the selected clinical variables, the presence of posts was the most decisive risk factor determining the success of endodontic surgeries.

Robotic and Microrobotic Tools for Dental Therapy

Robotic and microrobotic tools such as dental operating microscopes and dental endoscopes are being used extensively in dental therapy, which have a significant impact on dental therapy and education. Herein, this paper reviews the state of the art of robotic and microrobotic tools for dental therapy. This article starts with a brief introduction of current robotic and microrobotic tools for dental therapy and then displays their applications in various dental problems; strengths and weaknesses are also surveyed. Lastly, the conclusion and outlook are discussed, referring to the emerging dental clinic problems and demands. This review is expected to provide guidelines for the therapeutic application of robotic and microrobotic tools and to promote the development of robots in dentistry.

Accuracy and Reliability of Intraoral Radiographs in Determining the Cleanliness of Root Canals after Endodontic Retreatment

Objective:

This study aimed to evaluate the accuracy and reliability of periapical radiographs obtained with two different projections in determining the cleanliness of root canals in endodontic retreatment using the sectioned roots as a gold standard.

Methods:

The amount of residual root-filling material after endodontic retreatment procedures in 42 roots was assessed in radiographs and in microscopic photographs of the sectioned roots by five observers. Furthermore, the cleanliness of 80 roots was assessed based on orthogonal and mesio-angulated radiographs. Four parameters were used for the evaluation of cleanliness. Wilcoxon signed-rank tests and percentage agreement calculations were used for comparisons between the radiographs and the gold-standard observations and between the orthogonal and mesio-angulated radiographs, respectively. Intra- and interobserver reproducibility was tested using Kappa statistics and intra-class correlation tests. The statistically significance level was 0.05.

Results:

In general, significantly more residual root-filling material was detected in the photographs of the split roots (gold standard) than in the radiographs. Comparing orthogonal and eccentric projections, only slight differences in cleanliness were found. The intraobserver reproducibility was fair to almost perfect for radiographs and microscopic photographs. For all parameters, the reproducibility was better for the radiographs than for the microscopic photographs. The interobserver variability ranged from fair to almost perfect agreement for the radiographs.

Conclusion:

The accuracy of periapical radiographs was poor in determining the cleanliness of root canals after endodontic retreatment, whereas the reliability of the radiographs was fair. A mesio-angulated projection did not contribute essentially to the detection of residual root-filling materials.

Endoscopic System Based on Intraoral Camera and Image Processing

OBJECTIVE

In dentistry, dentists perform many treatments with a few visually magnified information. About deep area of root canals, it commonly relies on exploration carried out with the fingers of the dentist, because the root canal entrance is very small to be observed. In clinical practice, the intraoral camera and endoscopic systems are separate devices, and there are no sensors to capture both pictures of the whole tooth and those inside the root canal. Objective of this research is to combine the intraoral camera and endoscopic system facilitating to use clinical practice.

METHODS

We propose an endoscopic system based on the thin image fiber, SOPROLIFE intraoral camera as an image sensor, and a new adaptor to connect the two parts. We observed resolution charts with 50, 25, 10, and 5 line pairs (LP)/mm patterns. The acquired images are processed to both remove fixed-pattern noise using robust principal component analysis and enhance contrast.

RESULTS

The acquired images containing all LP/mm patterns were clear and showed higher contrast after processing. Visibility of the processed images is 1.7, 1.6, 2.2, and 1.9 times higher than that of the raw images for 50, 25, 10, and 5 LP/mm patterns, respectively.

CONCLUSION

Our fabricated endoscopic system based on the SOPROLIFE intraoral camera could observe 50, 25, 10, and 5 LP/mm patterns. After image processing, the noise was reduced, and high-contrast images were obtained.

SIGNIFICANCE

This system can be considered as a further step toward facilitating noninvasive and contactless systems in clinical practice.

An in vitro study to find the incidence of mesiobuccal 2 canal in permanent maxillary first molars using three different methods

Aim:

In-vitro study was done to evaluate the incidence of MB2 canals using three different methods (CBCT, CLINICAL ANALYSIS AND DENTAL LOUPES) and to compare the efficacy of the three methods in identifying the incidence of MB2 canals in maxillary permanent first molars.

Materials and Methods:

The study sample consisted of 120 extracted intact permanent maxillary molars. These extracted teeth were subjected to CBCT. Later the teeth were access opened with naked eye to find the incidence of MB2 canal, and then the teeth were visualised under dental loupe to locate MB2 canal if they were missed under naked eye. Results was statistically analysed by Mc Nemar's tests with Bonferroni correction, Chi square test and Cochran's Q test.

Result:

CBCT showed high incidence (68.3%) of MB2 canal in maxillary first molars and it showed to be a reliable method in detecting MB2 canal. When compared to dental loupe (52.5%) and naked eye (25%), the dental loupe improved the detection of MB2 canal.

Conclusion:

Within the parameter of this study in detecting the incidence of MB2 canal, using CBCT dental loupes and naked eye, detection of MB2 canal was significantly higher with CBCT followed by dental loupe and least with naked eye.

Ultrasound Assessment of Bone Healing after Root-end Surgery: Echoes Back to Patient's Safety

INTRODUCTION

The aim of this study was to present ultrasound imaging (UI) techniques as promising and safe tools for the follow-up of root-end surgery (RES) in vivo.

METHODS

The study included 8 patients who underwent RES. All were followed up using UI at 1 week, 1 month, 2 months, 3 months, and 6 months (if necessary) after RES. The bony crypt was defined on the ultrasound image, and the following observations were made during follow-up: cortical bone interruption and surface area measurement of the residual echoic bony crypt image.

RESULTS

In all cases, the hypoechoic image became hyperechoic, indicating gradual bone healing of the crypt. Compared with baseline, at 3 months a remaining cortical opening of 51.2% (±12.6%) and a bony crypt surface area of 24.3% (±10.8%) was detected for all patients. For 50% of the patients, the echographic follow-up ended at 3 months because the ultrasound waves could no longer enter the bony crypt. For 4 patients who attended the 6-month recall, a remaining cortical disruption of 43.2% (±9.9%) and a bony crypt surface area of 17.2% (±7%) compared with the baseline was noted.

CONCLUSIONS

UI is a promising follow-up tool for RES. It helps clinicians understand the initial stages of bone healing, allows close healing monitoring, and is radiation free.

No evidence that magnification devices improve the success of endodontic therapy

Data sourcesCochrane Oral Health group Trials Register, the Cochrane Central Register of Controlled Trials, Medline, US National Institutes of Health Trials Register, WHO-Clinical Trials Registry Platform for ongoing trials.Study selectionOnly randomised and quasi-randomised studies were pursued. No restrictions were placed on language or date of publication. The primary outcome sought was treatment success (complete healing or incomplete healing), uncertain healing and failure after one year of treatment, between one and four years and more than four years after treatment. Secondary outcomes considered for the inclusion criteria included outcomes related to the advantage of using a given magnification device in the clinical procedure such as; greater accuracy, the ease of removing broken instruments from the canal, quality of visualisation, quality of root end filling for the retrograde treatment, quality of perforation repair and the total time required for completing the clinical procedure.Data extraction and synthesisData would have been extracted by two review authors independently using a standardised data extraction form, and any disagreement would have been resolved by discussion and a third reviewer would have been consulted. Two review authors would have independently undertaken an assessment of the risk of bias.ResultsThe searches retrieved 1,234 studies. None of these satisfied the selection criteria, therefore no analysis was completed.ConclusionsNo article was identified in the current literature for the review that satisfied the inclusion criteria. It is unknown if and how the type of magnification device affects the treatment outcome considering the high number of factors that may have a significant impact on the success of endodontic therapy.

Treatment time for non-surgical endodontic therapy with or without a magnifying loupe

BACKGROUND

Use of magnifying loupe may increase the efficiency of dental care. This clinical trial compared the time in performing non-surgical endodontic therapy with or without the use of a magnifying loupe.

METHODS

Patients who required primary endodontic treatment in clinical trial centres at the University of Hong Kong (HKU) in Hong Kong and Peking University (PKU) in Beijing were invited to participate in this study. Two HKU dentists and 2 PKU dentists, forming 2 pairs of dentists with similar years of clinical experience, performed endodontic treatments according to the same procedures and used the same materials, either in single or multiple visits. They had no prior experience with the use of a magnifying loupe. One dentist from each pair was trained to use a magnifying loupe (x2.5). The treatment time was recorded.

RESULTS

Eighty-four PKU patients with a mean age of 42.8 years and 98 HKU patients with a mean age of 46.0 years were recruited in this study. Ninety-six teeth were treated with a magnifying loupe and 86 teeth were treated without a magnifying loupe. The results showed that treatment time was not associated with age, gender, tooth vitality, or the presence of apical radiolucency or sinus tract. The results of ANCOVA revealed the treatment time was associated with the clinic (HKU or PKU), root canal system (single or multiple), presence of preoperative pain, treatment visit (single or multiple), the use of a magnifying loupe, and the experience of the operator.

CONCLUSION

In this study, the use of a magnifying loupe could significantly reduce the endodontic treatment time.

TRIAL REGISTRATION

Clinical Trials ChiCTR-IOR-15005988 registered 15 February 2015.

Outcome of endodontic surgery: a meta-analysis of the literature--Part 2: Comparison of endodontic microsurgical techniques with and without the use of higher magnification

INTRODUCTION

The aim of this study was to investigate the outcome of root-end surgery. It identifies the effect of the surgical operating microscope or the endoscope on the prognosis of endodontic surgery. The specific outcomes of contemporary root-end surgery techniques with microinstruments but only loupes or no visualization aids (contemporary root-end surgery [CRS]) were compared with endodontic microsurgery using the same instruments and materials but with high-power magnification as provided by the surgical operating microscope or the endoscope (endodontic microsurgery [EMS]). The probabilities of success for a comparison of the 2 techniques were determined by means of a meta-analysis and systematic review of the literature. The influence of the tooth type on the outcome was investigated.

METHODS

A comprehensive literature search for longitudinal studies on the outcome of root-end surgery was conducted. Three electronic databases (ie, Medline, Embase, and PubMed) were searched to identify human studies from 1966 up to October 2009 in 5 different languages (ie, English, French, German, Italian, and Spanish). Review articles and relevant articles were searched for cross-references. In addition, 5 dental and medical journals (ie, Journal of Endodontics, International Endodontic Journal, Oral Surgery Oral Medicine Oral Pathology Oral Radiology and Endodontics, Journal of Oral and Maxillofacial Surgery, and International Journal of Oral and Maxillofacial Surgery) dating back to 1975 were hand searched. Following predefined inclusion and exclusion criteria, all articles were screened by 3 independent reviewers (S.B.S., M.R.K., and F.C.S.). Relevant articles were obtained in full-text form, and raw data were extracted independently by each reviewer. After agreement among the reviewers, articles that qualified were assigned to group CRS. Articles belonging to group EMS had already been obtained for part 1 of this meta-analysis. Weighted pooled success rates and a relative risk assessment between CRS and EMS overall as well as for molars, premolars, and anteriors were calculated. A random-effects model was used for a comparison between the groups.

RESULTS

One hundred one articles were identified and obtained for final analysis. In total, 14 studies qualified according to the inclusion and exclusion criteria, 2 being represented in both groups (7 for CRS [n = 610] and 9 for EMS [n = 699]). Weighted pooled success rates calculated from extracted raw data showed an 88% positive outcome for CRS (95% confidence interval, 0.8455-0.9164) and 94% for EMS (95% confidence interval, 0.8889-0.9816). This difference was statistically significant (P < .0005). Relative risk ratio analysis showed that the probability of success for EMS was 1.07 times the probability of success for CRS. Seven studies provided information on the individual tooth type (4 for CRS [n = 457] and 3 for EMS [n = 222]). The difference in probability of success between the groups was statistically significant for molars (n = 193, P = .011). No significant difference was found for the premolar or anterior group (premolar [n = 169], P = .404; anterior [n = 277], P = .715).

CONCLUSIONS

The probability for success for EMS proved to be significantly greater than the probability for success for CRS, providing best available evidence on the influence of high-power magnification rendered by the dental operating microscope or the endoscope. Large-scale randomized clinical trials for statistically valid conclusions for current endodontic questions are needed to make informed decisions for clinical practice.