Traditional Endodontic Surgery Versus Modern Technique: A 5-Year Controlled Clinical Trial

Two- and three-dimensional healing assessment after endodontic microsurgery in through-and-through periapical lesions: 5-year follow-up from a randomized controlled trial

AIM

To evaluate clinical and radiographic outcome of endodontic microsurgery in through-and-through periapical lesions at 1-year and 5-year follow-up with adjunct use of platelet-rich plasma (PRP).

METHODOLOGY

Thirty-two patients with large through-and-through periapical lesions were randomized in platelet-rich plasma (PRP) group and control group. Two-dimensional (2D) healing was evaluated with Molven's criteria and three-dimensional (3D) healing with modified PENN 3D criteria. Healing at resection plane (R), apical area (A), buccal cortex (BC), palatal cortex (PC) and overall bone healing (B) was assessed using CBCT scans. The volume of lesion was measured using ITK-Snap software. The analysis included comparison of 1- to 5-year intragroup (Friedman test/McNemar test) and intergroup scoring (Chi-square/ Mann-Whitney test). Logistic regression analysis was performed to determine the effect of various factors on healing at 5 years.

RESULTS

Out of 32 patients/59 teeth evaluated after 1-year of endodontic microsurgery, 24 patients/44 teeth reported at 5 - year follow-up. Healing assessment with modified PENN 3D criteria revealed improvement in overall success rate of 66.7% at 1 year to 83.3% at 5 years, with no deterioration in any healing category. PRP group exhibited significantly better 3D healing than control group; both at 1 year (84.6% vs. 45.5%) and 5 years (100% vs. 63.6%). A significantly higher number of completely healed teeth were observed in PRP group than the control group at 5 years with respect to R, BC and B parameters. A volume reduction of 88% (91.4% PRP, 84% control) was depicted at 1 year and 94% (97.1% PRP, 91.1% control) at 5 years. None of the recorded factors including age, gender, size of lesion, preoperative swelling and sinus, histology of lesion, use of PRP, tooth location, preoperative buccal bone had significant effect on 3D healing at 5 years.

CONCLUSIONS

This 5-year study suggested improvement in 3D radiographic healing of large through-and-through periapical lesions from 1 to 5 years with no deterioration in any healing parameter in both control and PRP groups. The additional use of PRP led to significantly better healing in such lesions. RACB index using CBCT allows better estimation of healing at resected, apical and cortical plane over modified PENN 3D or Molven's criteria.

The outcome of combined use of iRoot BP Plus and iRoot SP for root-end filling in endodontic microsurgery: a randomized controlled trial

OBJECTIVES

Root-end filling is important for the clinical outcome of endodontic microsurgery. Our previous study showed that combined application of iRoot BP Plus Root Repair Material (BP-RRM) and iRoot SP Injectable Root Canal Sealer (SP-RCS) in root-end filling exhibited better apical sealing as compared to the application of BP-RRM alone. The aim of this randomized controlled clinical trial was to evaluate the effect of the combined use of BP-RRM and SP-RCS on the prognosis of teeth with refractory periapical diseases after endodontic microsurgery.

MATERIALS AND METHODS

240 teeth with refractory periapical diseases scheduled for endodontic microsurgery were randomly divided into BP-RRM/SP-RCS group (n = 120) and BP-RRM group (n = 120). The patients were followed up at 3 months, 6 months, and 12 months after endodontic microsurgery. Pre- and post-operative clinical and radiographic examinations were performed to evaluate the treatment outcome. The 1-year success rate of endodontic microsurgery in BP-RRM/SP-RCS and BP-RRM groups was compared by Chi-square test. Factors that might impact the prognosis were further analyzed using Chi-square test or Fisher's exact test.

RESULTS

A total of 221 teeth completed the 12-month follow-up. The 1-year success rates of the BP-RRM/SP-RCS and BP-RRM groups were 94.5% (104/110) and 92.8% (103/111), respectively. The combined use of BP-RRM and SP-RCS achieved a clinical outcome comparable to BP-RRM alone (P = 0.784). Tooth type (P = 0.002), through-and-through/apico-marginal lesion (P = 0.049), periodontal status (P < 0.0001), and Kim's lesion classification (P < 0.0001) were critical factors associated with the 1-year success of endodontic microsurgery.

CONCLUSIONS

The combined use of BP-RRM and SP-RCS is a practicable method for root-end filling in endodontic microsurgery with a satisfactory 1-year clinical outcome.

CLINICAL RELEVANCE

The combined application of BP-RRM and SP-RCS in EMS is an effective root-end filling method with a satisfactory 1-year clinical outcome.

TRIAL REGISTRATION

This study was registered in the Chinese Clinical Trial Registry (ChiCTR2100052174).

Assessment of Quality and Readability of Online Patient-Centered Arabic Web-Based Knowledge About Apicoectomy

Background Endodontic microsurgery (apicectomy) can be considered in cases of persistent infection that is resistant to conventional root canal treatment. The aim of this study was to evaluate the quality and readability of the available online information regarding the apicectomy procedure in Arabic. Methods Online search on the three most commonly used websites (Google, Yahoo, and Bing) using one keyword. The first 100 websites from each search were analyzed for quality and readability using DISCERN instrument scores, the Journal of the American Medical Association (JAMA) benchmarks, the Health On the Net (HON) seal, Flesch Reading Ease Scores (FRES), Flesch-Kincaid Grade Level (FKGL), and the Simplified Measure of Gobbledygook (SMOG) Index. Results Searching using the Arabic translation for "root end resection surgery" revealed 349,900 websites. Following the inclusion criteria, 31 websites were selected and evaluated in this study. The selected websites belonged to either non-profit organizations or commercial websites. The quality of most of the selected websites received a moderate score (83.9%) using the DISCERN tool. None of the selected websites obtained the HON seal. Quality evaluation using the JAMA benchmarks revealed that currency was the most achieved item (45.2%), followed by authorship (22.6%). Evaluation of the readability of the selected websites using the FRES, FKGL, and SMOG showed that the included websites were considered readable. Conclusion Although the included websites were readable, the quality of the websites was moderate. There is an urgent need to create more trustworthy and readable websites explaining the different endodontic treatments.

New-designed 3D printed surgical guide promotes the accuracy of endodontic microsurgery: a study of 14 upper anterior teeth

We aimed to design a novel three-dimensional (3D) printed surgical guide and evaluate its accuracy in assisting endodontic microsurgeries. A new 3D printed surgical guide was designed by computer-aided design and computer-aided manufacturing (CAD/CAM) technology and applied to 7 patients who underwent endodontic microsurgeries of upper anterior teeth from 2020.01 to 2020.12 as the experimental group. 7 patients who suffered from endodontic microsurgeries operated by the same surgeon without using the surgical guide from 2019.01 to 2019.12 were selected as the control group. Cone beam computed tomography (CBCT) was performed more than 12 months after operation, and the accuracy of apical resection was compared between the two groups. The accuracy of the microsurgery focused on the length and angle of the root apical resection. In the study, CBCT data and oral digital scanning data were used to reconstruct 3D models of periapical lesions with soft and hard tissue information, based on which we designed the new 3D printed surgical guides. The guides were successfully applied to the apectomy in endodontic microsurgeries. The deviation of the apical resection length of the experimental group (0.467 ± 0.146 mm) was better than that of the control group (1.743 ± 0.122 mm) (P < 0.0001), and the deviation of the apical resection angle of the experimental group (9.711 ± 3.593°) was significantly less than that of the control group (22.400 ± 3.362°) (P < 0.0001). The 3D-printed surgical guide could effectively guide endodontic microsurgery and improve its accuracy by fixing both the position and the angle of apectomy. The new type of surgical guide could accurately localize the root apex and guide the apical resection.

Outcomes reporting in systematic reviews on surgical endodontics: A scoping review for the development of a core outcome set

BACKGROUND

Evidence-informed decision-making in healthcare relies on the translation of research results to everyday clinical practice. A fundamental requirement is that the validity of any healthcare intervention must be supported by the resultant favourable treatment outcome. Unfortunately, differences in study design and the outcome measures evaluated often make it challenging to synthesise the available research evidence required for secondary research analysis and guideline development. Core outcome sets (COS) are defined as an agreed standardised set of outcomes which should be measured and reported as a minimum in all clinical trials on a specific topic. The benefits of COS include less heterogeneity, a reduction in the risk of reporting bias, ensuring all trials contribute data to facilitate meta-analyses, and given the engagement of key stakeholders, it also increases the chances that clinically-relevant outcomes are identified. The recognition of the need for COS for assessing endodontic treatment outcomes lead to the development of Core Outcome Sets for Endodontic Treatment modalities (COSET) protocol, which is registered (No. 1879) on the Core Outcome Measures in Effectiveness Trials (COMET) website.

OBJECTIVES

The objectives of this scoping review are to: (1) identify the outcomes assessed in studies evaluating surgical endodontic procedures; (2) report on the method of assessment used to measure the outcomes; (3) and assess selective reporting bias in the included studies. The data obtained will be used to inform the development of COS for surgical endodontics.

METHODS

A structured literature search of electronic databases and the grey literature was conducted to identify systematic reviews on periradicular surgery (PS), intentional replantation (IR) and tooth/root resection (RR), published between January 1990 and December 2020. Two independent reviewers were involved in the literature selection, data extraction and the appraisal of the studies identified. The type of intervention, outcomes measured, type of outcomes reported (clinician- or patient-reported), outcome measurement method, and follow-up period, were recorded using a standardised form.

RESULTS

Twenty-six systematic reviews consisting of 19 studies for PS, three studies for IR and four studies for RR were selected for inclusion. Outcome measures identified for PS and IR included pain, swelling, mobility and tenderness, outcomes related to periodontal/soft tissue healing (including sinus tract), periradicular healing, tooth survival, life impact (including Oral-Health-Related-Quality-of-Life), resource use and/or adverse effects. For RR, in addition to tooth survival, endodontic complications, and adverse effects, the outcome measures were primarily periodontal-related, including pocket depth reduction, attachment gain, periodontal disease, and periodontic-endodontic lesions. The majority of outcome measures for PS, IR, and RR were assessed clinically, radiologically and/or via patient history. Specific tools such as rating scales (Visual Analog Scale, Verbal rating Scale, Numerical Rating Scale, and other scales) were used for the assessment of pain, swelling, and tenderness, and validated questionnaires were used for the assessment of oral health-related quality of life. The range of follow-up periods were variable, dependent on the outcome measure and the type of intervention.

CONCLUSIONS

Outcome measures, method of assessment and follow-up periods for PS, IR and RR were identified and categorised to help standardise the reporting of outcomes for future research studies. Additional outcome measures that were not reported, but may be considered in the COSET consensus process include loss of root-end filling material, number of clinic visits, surgery-related dental anxiety and muco-gingival aesthetic-related measures, such as scarring, black triangles, root surface exposure, and tissue discolouration.

Investigating the appropriateness of surgical endodontic referrals to a West Sussex regional referral unit

Aim To audit the appropriateness, after triage, of surgical endodontic referrals to Queen Victoria Hospital, a regional referral unit in West Sussex. To discuss the current referral pathway with the aim of improving general dental practitioner (GDP) understanding of indications for surgical endodontics via the referral process.Methodology A three-year retrospective review of all surgical endodontic referrals made to Queen Victoria Hospital, East Grinstead was completed. This was inclusive of all referrals made via the National Health Service (NHS) Vantage Rego e-referral system and GDP referral letters. The quality of referrals was analysed as indicated or contraindicated in accordance with the Royal College of Surgeons guidelines for surgical endodontics and periradicular surgery.Results Out of the 34 referrals included in data analysis, 50% contained one or more contraindication for surgical intervention. The most commonly recorded contraindications to treatment were poor-quality root canal treatment, periodontal disease compromising the long-term success of treatment and a poor coronal seal deeming the tooth unrestorable post-surgical intervention.Conclusions A more efficient surgical endodontic referral system will aid resource allocation within the NHS. These results are a first step to aiding necessary modification of the primary care referral pathway to achieve a more effective service for patients, with improved acceptance rate of referrals and better surgical outcomes.

Occurrence of Vertical Root Fractures after Apical Surgery: A Retrospective Analysis

INTRODUCTION

Vertical root fractures (VRFs) are among the most frequent causes of tooth loss, mainly of endodontically treated teeth. However, very few data is available about the occurrence of VRFs following apical surgery.

METHODS

Patient charts from 864 patients with 1058 teeth treated with apical surgery (September 1999 to December 2018) were retrospectively evaluated, if a VRF had occurred after surgery. The following, possibly influencing factors were analyzed: sex and age, type of treated tooth, primary versus resurgery, technique of root-end preparation, and timepoint of VRF diagnosis. Endpoints were either tooth extraction or the last follow-up.

RESULTS

The study cohort (55% women, 45% men) had a mean age of 52.00 ± 13.97 years (range 9-93 years). The overall rate of VRFs after apical surgery was 4% (42 of 1058 teeth). Among these 42 teeth, 33.3% were mandibular first molars and 26.2% were maxillary second premolars. The most frequently affected root was the mesial root of mandibular first molars (28.6%). With regard to the study parameters, significant differences of VRF rates were observed only for the type of tooth treated.

CONCLUSIONS

A low VRF rate of 4% was observed in this study. VRFs commonly occurred in maxillary premolars and mandibular molars, with the mesial root of mandibular first molars affected most frequently. This is in line with previous reports about VRFs in endodontically treated teeth without additional apical surgery.

The significance of epidermal growth factor receptor uncommon mutations in non-small cell lung cancer: A systematic review and critical appraisal

Uncommon epidermal growth factor receptor (EGFR) mutations collectively account for 10% of EGFR mutations, harboring heterogeneous molecular alterations within exons 18-21 with clinically variable responses to EGFR tyrosine kinase inhibitors (TKIs) in advanced Non-Small Cell Lung Cancer (NSCLC) patients. In addition, with the introduction of different NGS gene approach an improvement of EGFR mutations detection was reported. Today, no specific studies have prospectively evaluated uncommon sensitizing mutations in detail and no firm standard of care has been established in the first-line setting. The aim of this comprehensive review is to critically consider the clinical role of uncommon EGFR mutations highlighting the results of several in vitro and in vivo studies, which singly evaluated the sensitivity of uncommon mutations to currently European of Medicines Agency (EMA)-approved EGFR TKIs in cell lines, xenograft models and humans, in order to obtain a practical guide for refining the clinical decision-making process.

Accuracy and clinical safety of guided root end resection with a trephine: a case series

Background

Root-end resection is an endodontic surgical intervention that requires high precision so that all ramifications and lateral canals so as infected tissues are eliminated. An exploratory study was conducted to justify the clinical safety and accuracy of guided root-end resection with a trephine.

Methods

Fourteen root-end resections were performed in 11 patients. With the aid of computer tomography and rapid prototyping a stereolithographically fabricated, tooth-supported surgical template was used to guide trephinations. Surgery was performed using the printed surgical stent and a trephine was used not only for the osteotomy but for the root end resection as well.

Results

The root end was successfully and completely resected by the trephine in all cases. No intraoperative complications were observed in any of the cases, and the patients were free of symptoms indicating recurrence or complications at the 6-month follow-up. The median angular deviation of the trephination was 3.95° (95% CI: 2.1–5.9), comparable to the angular deviation of guided implant surgery. The mean apex removal error (ARE) was 0.19 mm (95% CI: 0.03–0.07). The mean osteotomy depth error (ODE) was 0.37 mm (95% CI: 0.15–1.35). Overpenetration was a characteristic finding, which indicates the necessity of a stop-trephine.

Conclusions

Within the limitations of this study, we conclude that our results support the use of guided trephination for root-end resection.

Bimaxillary orthognathic surgery with a conventional saw compared with the piezoelectric technique: a longitudinal clinical study

The only cutting technique used for osteotomies in orthognathic surgery for many years has been a saw, but recently piezoelectric surgery has been introduced as a possible alternative. The aim of this study was to find out if piezoelectric surgery can be more comfortable for patients having orthognathic surgery. A total of 25 patients with dentofacial deformities (seven male and 18 female), were treated from January 2016 to September 2017. In 11 patients, osteotomies were made using a conventional saw, while in 14 a piezoelectric device was used. The variables assessed were: operating time, postoperative swelling, postoperative pain, and cutaneous sensitivity of the upper and lower lips. The duration of operation for the piezosurgery group was significantly longer than that for controls, but the patients had less swelling at all follow-up visits, and the difference was significant at the 30-day follow-up (p=0.045). Those who had piezosurgery had significantly less pain at the three-day follow up (p=0.035). There was a significant difference in cutaneous sensitivity only for the right side of the upper lip and only at the one-day follow-up. We conclude that piezoelectric surgery offers some advantages in lessening swelling and the perception of pain after orthognathic surgery, but further investigations are required.

Mineral trioxide aggregate and other bioactive endodontic cements: an updated overview - part II: other clinical applications and complications

Mineral trioxide aggregate (MTA) is a dental material used extensively for vital pulp therapies (VPT), protecting scaffolds during regenerative endodontic procedures, apical barriers in teeth with necrotic pulps and open apices, perforation repairs as well as root canal filling and root-end filling during surgical endodontics. A number of bioactive endodontic cements (BECs) have recently been introduced to the market. Most of these materials have calcium and silicate in their compositions; however, bioactivity is a common property of these cements. These materials include the following: BioAggregate, Biodentine, BioRoot RCS, calcium-enriched mixture cement, Endo-CPM, Endocem, EndoSequence, EndoBinder, EndoSeal MTA, iRoot, MicroMega MTA, MTA Bio, MTA Fillapex, MTA Plus, Neo MTA Plus, Ortho MTA, Quick-Set, Retro MTA, Tech Biosealer, and TheraCal LC. It has been claimed that these materials have properties similar to those of MTA but without the drawbacks. In Part I of this review, the available information on the chemical composition of the materials listed above was reviewed and their applications for VPT was discussed. In this article, the clinical applications of MTA and other BECs will be reviewed for apexification, regenerative endodontics, perforation repair, root canal filling, root-end filling, restorative procedures, periodontal defects and treatment of vertical and horizontal root fractures. In addition, the literature regarding the possible drawbacks of these materials following their clinical applications is reviewed. These drawbacks include their discolouration potential, systemic effects and retreatability following use as a root filling material. Based on selected keywords, all publications were searched regarding the use of MTA as well as BECs for the relevant clinical applications. Numerous publications were found regarding the use of BECs for various endodontic applications. The majority of these investigations compared BECs with MTA. Despite promising results for some materials, the number of publications using BECs for various clinical applications was limited. Furthermore, most studies had several methodological shortcomings and low levels of evidence.

Three-year outcomes of apicectomy (apicoectomy): Mining an insurance database

OBJECTIVES

The outcome of apicectomy in clinical reality is supposed to be different compared to outcomes reported from clinical trials. The objective of this study was to measure the outcome of apicectomies under practice conditions by mining an insurance data base.

METHODS

This retrospective study was based on claims data of a major German national health insurance company (BARMER GEK). Through the company's data warehouse fee codes and treatment dates were accessible and allowed the tracing of clinical courses. Kaplan-Meier survival analyses for the target event 'extraction' were conducted for all teeth that underwent apicectomies within a 3 year period. Testing for differences among survival rates across groups was performed with the Log-Rank-test.

RESULTS

A total of 93,797 teeth in 77,636 patients could be traced after apicectomy. The cumulative 3-year survival rate was 81.6%. Anterior teeth showed a significantly higher survival rate of 84.0% compared to premolars (80.4%) and molars (80.2%). The survival rate in men (83.5%) was significantly higher than in women (80.6%). Analysis of survival by age revealed continuously declining survival rates with age (93.3% for subjects under 18 years of age to 75.6% for subjects over 84 years of age).

CONCLUSIONS

The 3-year outcomes of apicectomy were still acceptable for an intervention that is mostly conducted as a retreatment after failure of a preceding measure. However at a population level, the question remains to be answered whether other treatment options would potentially be more effective.