A Novel Diagnostic and Treatment Approach to an Unusual Case of Dens Invaginatus in a Mandibular Lateral Incisor Using CBCT and 3D Printing Technology

BACKGROUND

This case report demonstrates the use of three-dimensional (3D) models produced from a cone beam computed tomographic (CBCT) volume to develop a treatment strategy for a rare type of dens invaginatus (DI) in a mandibular incisor.

METHODS

A patient with DI Type IIIa presented for endodontic treatment. Following CBCT evaluation, the complex morphologic nature of the invagination required additional diagnostic tools for treatment planning. The fabrication of 3D models provided clarity regarding the treatment strategy. Treatment involved intracanal medication with calcium hydroxide Ca(OH)2, nonsurgical root canal therapy (NS-RCT) of the main canal, and endodontic surgery for the DI anomaly using mineral trioxide aggregate (MTA), bone graft, and platelet-rich fibrin (PRF) membrane.

RESULTS

The use of 3D models provided an invaluable guide for proper treatment. Complicating factors were diagnosed and planned for accordingly.

CONCLUSIONS

It is difficult to appreciate the anatomical complexity, the extent, and the nature of the invagination of rare Type III DI morphology. CBCT imaging and 3D models played a critical role in the pre-treatment planning to ensure a predictable outcome. A 3D model is recommended as a diagnostic tool in treating complex cases where the DI morphology is wide, oblique, or the foraminal opening is irregular.

Complete idiopathic resorption of distobuccal root of a maxillary first molar: A case report

Key Clinical Message

This case report provides a rare case of idiopathic root resorption in maxillary first molar and suggests the importance of CBCT in the diagnosis and treatment outcome of complex endodontic diseases. Endodontic surgery is an effective method for treating teeth with persistent apical periodontitis.

Abstract

Idiopathic root resorption is an unexplained root resorption when the patient experiences root resorption without any local or systemic factors. Early diagnosis and appropriate treatment are crucial for long-term outcomes.

Stabilizing bony plate in guided endodontic surgery using an innovative approach

Endodontic microsurgery in tandem with advanced radiographic techniques has led to the emergence of guided surgeries. Preservation of the cortical bone to enhance the healing and stabilization of tissues surrounding the tooth of concern can now be facilitated by bone cement used in the field of orthopedics. This case report details a guided endodontic surgery technique in 17 years old where a traumatic infliction leads to a phoenix abscess. The technique elaborated emphasizes on the three-dimensional printing of a surgical template with the help of cone-beam computed tomography, followed using a medical-grade bone cement in the most minimal manner to reposition the buccal cortical bone. A 12-month-old follow-up revealed the patient to be asymptomatic with a flawless periapical region radiographically. This case testifies that the optimum use of available biomedical material in surgical endodontics can assure a predictable prognosis.

The effects of different regenerative technologies and materials on wound healing after surgical endodontic therapy: A meta-analysis

A meta-analysis was performed to assess the effects of different regenerative technologies and materials on wound healing after surgical endodontic therapy and provide a reference for surgical endodontic treatment. We searched for studies on the use of regenerative technologies and materials in surgical endodontic therapy via PubMed, MEDLINE, EMBASE, Web of Science, China National Knowledge Infrastructure (CNKI), and Wanfang Data from the time of database creation to December 2022. Two researchers independently screened the literature, extracted information based on the inclusion and exclusion criteria, and evaluated the quality of the included studies. A meta-analysis was performed using Review Manager 5.4. The results showed that the use of regenerative technologies and materials significantly reduced wound healing failures (risk ratio [RR]: 0.30, 95% confidence intervals [CI]: 0.22-0.40, p < 0.001). Moreover, autologous platelet concentrations (APCs) (RR: 0.28, 95% CI: 0.15-0.53, p < 0.001) and collagen membrane plus bovine-derived hydroxyapatite (RR: 0.27, 95% CI. 0.12-0.61, p = 0.002) were more effective in improving wound healing failure rates than collagen membrane alone (RR: 0.51, 95% CI: 0.20-1.25, p = 0.140). Our findings showed that APCs, as well as collagen membrane plus bovine-derived hydroxyapatite, significantly improved wound healing after surgical endodontic therapy. In contrast, collagen membrane alone did not significantly improve wound healing outcomes. However, currently available studies vary significantly in sample size and methodologies. Hence, high-quality randomised controlled studies with large sample sizes are necessary to validate our findings.

The Effectiveness of Autologous Platelet Concentrates in the Clinical and Radiographic Healing after Endodontic Surgery: A Systematic Review

Regenerative techniques are increasingly applied in endodontic surgery, but different materials may have varying impacts on soft and hard tissue healing. This systematic review aims to evaluate the effectiveness of autologous platelet concentrates (APCs) in clinical and radiographic healing after endodontic surgery. The data for this systematic review were processed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for improving the reporting of systematic reviews and meta-analyses. A literature search was conducted until October 2023 on PubMed, Scopus, and Cochrane Databases. Randomized controlled trials and controlled clinical trials addressing the use of APCs in patients who presented persistent periapical lesions and needed periapical surgery were included. Dual publications, narrative reviews, systematic reviews, case series, questionnaires, animal studies, case reports, letters to the editor, in vitro studies, and abstracts were excluded. In total, the search resulted in 14 papers. Clinical and radiographical findings were reported, showing that when APCs were used, patients exhibited less pain and swelling and a greater reduction of apical radiolucency after 12 months follow-up on average. However, the moderate/high risk of bias of included studies and their high heterogeneity, do not allow one to draw definitive conclusions on the effectiveness of APC after endodontic surgery.

Cost-effectiveness analysis of full versus selective root canal retreatment

AIM

Selective root-canal retreatment has been proposed as an alternative to full retreatment in multirooted, root-canal-filled teeth with evidence of apical pathology, where only the affected root(s) is retreated. Whilst this option may save costs initially, failures and retreatments may compensate for these initial savings. We assessed the cost-effectiveness of full versus selective root-canal retreatment using data from a recent clinical pilot study, employing a modelling approach.

METHODOLOGY

A Markov model was constructed to follow up a previously root-canal treated maxillary molar with apical pathology on a single root (mesio-buccal), receiving either selective or full root-canal retreatment. A private-payer perspective in Dutch health care was adopted. Permanent molar teeth with apical lesions on the mesial root were simulated over the lifetime of initially 50-year-old patients. Teeth could have endodontic complications and require interventions such as retreatment or tooth extraction and replacement. Costs were calculated based on the Dutch dental fee catalogues. Monte-Carlo microsimulations were performed to assess lifetime costs and effectiveness (measured as tooth retention time), and the resulting cost-effectiveness. Probabilistic joint uncertainty and sensitivity analyses were performed, and cost-effectiveness at different willingness-to-pay-thresholds was evaluated.

RESULTS

In the base-case scenario, selective retreatment was less costly (2137; 2.5%-97.5% percentiles: 1944-2340 Euro) and more effective (19.6; 18.3-20.8 Years) than full retreatment (2495; 2305-2671 Euro; 16.5; 15.2-17.9 Years) in 100% of the simulations and regardless of the willingness-to-pay threshold. Only in a worst case scenario was selective retreatment more costly, but remained more effective.

CONCLUSIONS

Selective retreatment, when clinically applicable, is likely to be more cost-effective than full retreatment in endodontically treated molars with persistent apical periodontitis. Our results should be interpreted with caution because the quality of the underlying data is limited.

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.

Augmented Reality-Guided Apicoectomy Based on Maxillofacial CBCT Scans

Implementation of augmented reality (AR) image guidance systems using preoperative cone beam computed tomography (CBCT) scans in apicoectomies promises to help surgeons overcome iatrogenic complications associated with this procedure. This study aims to evaluate the intraoperative feasibility and usability of HoloLens 2, an established AR image guidance device, in the context of apicoectomies. Three experienced surgeons carried out four AR-guided apicoectomies each on human cadaver head specimens. Preparation and operating times of each procedure, as well as the subjective usability of HoloLens for AR image guidance in apicoectomies using the System Usability Scale (SUS), were measured. In total, twelve AR-guided apicoectomies on six human cadaver head specimens were performed (n = 12). The average preparation time amounted to 162 (±34) s. The surgical procedure itself took on average 9 (±2) min. There was no statistically significant difference between the three surgeons. Quantification of the usability of HoloLens revealed a mean SUS score of 80.4 (±6.8), indicating an "excellent" usability level. In conclusion, this study implies the suitability, practicality, and simplicity of AR image guidance systems such as the HoloLens in apicoectomies and advocates their routine implementation.

Bone Regeneration Effect of Nanochitosan with or without Temporally-controlled Release of Dexamethasone

INTRODUCTION

Chitosan is a cationic biopolymer and its modification as a nanoparticle, as well as loading a corticosteroid on it, may enhance its bone regenerative effect. The aim of this study was to investigate the bone regenerative effect of nanochitosan with or without dexamethasone.

METHODS

Under general anesthesia, four cavities were created in the calvarium of 18 rabbits and filled with either nanochitosan, nanochitosan with a temporally-controlled release of dexamethasone (nanochitosan+dexamethasone), an autograft, or left unfilled (control). The defects were then covered with a collagen membrane. The rabbits were randomly divided into 2 groups and were sacrificed at 6 or 12 weeks post-surgery. The new bone type, osteogenesis pattern, foreign body reaction, as well as the type and severity of the inflammatory response were evaluated histologically. The amount of new bone was determined using histomorphometry and cone-beam computed tomography (CBCT). A one-way ANOVA with repeated-measures was performed to compare results between the groups at each interval. A T-test and Chi-square were also conducted to analyze changes in variables between the two intervals.

RESULTS

Nanochitosan and the combination of nanochitosan and dexamethasone significantly increased the combination of woven and lamellar bone (P=0.007). No sample showed a foreign body reaction or any acute or severe inflammation. Chronic inflammation was significantly decreased in number (P=0.002) and severity (P=0.003) over time. There was no significant difference between the extent and pattern of osteogenesis amongst the four groups, as evaluated by histomorphometry and CBCT at each interval.

CONCLUSION

Nanochitosan and nanochitosan+dexamethasone were comparable to the gold standard of autograft regarding the type and severity of inflammation, as well as the level and pattern of osteogenesis, yet they induced more woven and lamellar bone.

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.

Comparison of Static and Dynamic Navigation in Root End Resection Performed by Experienced and Inexperienced Operators: An In Vitro Study

INTRODUCTION

This study aimed to compare the effects of static navigation (SN), a dynamic navigation system (DNS), and the freehand (FH) technique in root end resection and the differences between these effects according to the level of experience of the operator.

METHODS

Maxillary models reconstructed with Mimics software (Materialise, Leuven, Belgium) were 3-dimensionally printed and divided according to the experimental technique (FH, SN, or DNS) and the operator (experienced or inexperienced). SN was designed using 3-matic Medical software (Materialise) and printed, and a surgical approach plan for DNS was established and performed using DCARER (Suzhou, China) software. The accuracy, efficiency, and safety of the resections were assayed.

RESULTS

The length, angle, volume, and depth deviations of the root end resections were significantly lower in the SN and DNS group compared with the FH group. SN significantly improved the efficiency of both operators, whereas DNS only improved the efficiency of the inexperienced operator. No difference between the SN and DNS groups was found, except for the time required for the surgery. No mishaps occurred during surgery in the SN or DNS group. The number of mishaps with the FH technique when used by the inexperienced operator was significantly higher than that registered for the rest of the groups. No interaction effect between technique and operator experience level was detected.

CONCLUSIONS

Regardless of operator experience, both SN and DNS could improve the accuracy and safety of root end resection. SN significantly improved the chairside efficiency of both operators, whereas DNS was more helpful for the inexperienced operator.

Surgical endodontic treatment of maxillary incisors: Case report

This study aims to highlight the possibility of an effective endodontic surgical surgery when nonsurgical treatment of the right maxillary anterior teeth has failed. One year after the apicoectomy, the periapical lesion has completely healed, new bone has formed, and the patient is symptom-free.

Present Status and Future Directions - Surgical Endodontics

Endodontic surgery encompasses several procedures for the treatment of teeth with a history of failed root canal treatment, such as root-end surgery, crown- and root resections, surgical perforation repair, and intentional replantation. Endodontic microsurgery is the evolution of the traditional apicoectomy techniques and incorporates high magnification, ultrasonic root-end preparation and root-end filling with biocompatible filling materials. Modern endodontic surgery uses the dental operating microscope, incorporates cone-beam computed tomography (CBCT) for preoperative diagnosis and treatment planning, and has adopted piezoelectric approaches to osteotomy and root manipulation. Crown- and root resection techniques have benefitted from the same technological advances. This review focuses on the current state of root-end surgery by comparing the techniques and materials applied during endodontic microsurgery to the most widely used earlier methods and materials. The most recent additions to the clinical protocol and technical improvements are discussed, and an outlook on future directions is given. While non-surgical retreatment remains the first choice to address most cases with a history of endodontic failure, modern endodontic microsurgery has become a predictable and minimally invasive alternative for the retention of natural teeth.

Sealing ability of two root-end filling materials at different retro-preparation lengths

PURPOSE

The aim of the present study was to evaluate the sealing performance, expressed as microleakage (ML), of two root-end filling materials when used at different retro-preparation lengths.

METHODS

Fifty single-rooted human teeth were collected for the study. The teeth were cut at the cement-enamel junction and endodontic treatment was performed. Each root was cut at 3 mm from the apex and then stored in wet condition. The teeth were divided into three groups according to the retro-preparation length: control group (no retro-preparation); group 1 (retro-preparation of 3 mm); group 2 (retro-preparation of 9 mm). The teeth were equally allocated to either Biodentine or Super EBA treatment group. The teeth were immersed in 3% methylene blue dye solution for 24 h. The samples were split longitudinally and the depth of dye penetration was examined through light microscopy.

RESULTS

No significant statistical differences were found at different retro-preparation lengths (P > 0.05). Differences were found between materials (P > 0.05).

CONCLUSION

Biodentine showed significantly lower ML when compared to Super-EBA and no statistical significative differences were observed when samples were retro-prepared at 3 mm or 9 mm.

Bone Regenerative Biomaterials in Periapical Surgery: A Systemic Review and Meta-Analysis

INTRODUCTION

Successful treatment in the endodontics and periodontics depends on the periapical status. Hence, in the present meta-analysis, we evaluate the various bone regenerative materials in the periapical surgeries.

MATERIALS AND METHODS

Online data were collected from the search engines of EBSCO, PubMed, Google Scholar, and Scopus. The searched terms were bone regenerative, bone grafts, bio materials, periapical surgery, and endodontic surgery. Based on the PRISMA guidelines, the meta-analysis was performed. The studies for the past 10 years were considered that included at least 10 patients. The translatable articles were included that had the human studies that were clinical studies and/or trials and also had the bone regenerative materials used in the procedure.

RESULTS

A total of 475 articles were selected, of which 30 were selected based on the criteria. Of these, after the removal of the 21 duplicate articles, 9 articles were finalized. The meta-analysis showed that when the bone graft materials are used along with the barriers for the regeneration, there were observed higher success rates.

CONCLUSIONS

The bone regenerative materials can be used for the successful outcome for the periapical surgeries. The guided tissue regeneration along with the bone regenerative materials may aid in the good prognosis of the endodontic and periodontal cases.

Healing after surgical retreatment at four time points: A retrospective study

AIM

To evaluate the outcome of surgical retreatment at four time points, that is 6, 12, 24 and 48 months post-operatively, and to search for prognostic factors that may affect the outcome.

METHODOLOGY

Clinical records and intraoral periapical radiographs were collected from patients who had undergone surgical retreatment between 2009 and 2015 and attended 6-, 12-, 24- and 48-month follow-up visits. Surgical retreatment was performed by one endodontist and involved minimal root-end resection and maximal length root-end preparation using prebent ultrasonic files. Outcomes were categorized as complete, incomplete, uncertain or unsatisfactory healing, based on clinical and radiographic findings. The complete and incomplete categories were pooled and considered successes, while uncertain and unsatisfactory outcomes were considered failures. Changes in healing outcome were analysed using the McNemar-Bowker test, and prognostic factors were analysed using univariate analysis.

RESULTS

The study cohort included 297 patients with 384 teeth. The overall success rate after 48 months was 90.6% compared with 88.5%, 93% and 92.4% after 6, 12 and 24 months respectively. Age, gender, presence of isthmus and length of canal preparation had no significant influence on the outcome. Lesion size and tooth type had a significant influence only after 6 and 12 months, respectively, with no significant differences at other time points. Fifty per cent of the teeth classified as unsatisfactory or uncertain healing at the 6 months follow-up improved to incomplete or complete healing after 12 months. None of the cases classified as unsatisfactory healing after 12 months subsequently improved, and only 2 cases that were classified as uncertain healing after 12 months improved after 24 months.

CONCLUSIONS

Surgical retreatment was found to be a predictable procedure with a high success rate of 90.6% after 4 years. Over the follow-up periods, only a minor regression in the success rate was found. The 12 months follow-up results closely indicated the long-term outcome of surgical retreatment.

A Comparative Study of Biocompatibility in Rat Connective Tissue of a New Mineral Trioxide Compound (Theracal) versus MTA and a Bioactive G3 Glass

The aim of this paper was to assess the differences in tissue response to implantation during 15, 30 and 45 days in the subcutaneous connective tissue of Wistar rats from three biomaterials: Angelus MTA^®, Theracal LC^®, and Angelus MTA^® to which 25% bioglass G3 was added. Twenty-four Wistar rats were used, the materials were inserted into the rat’s dorsal area in silicone tubes 5 mm long by 1.5 mm diameter. Histological reaction was assessed at 15, 30, and 45 days after implantation. They were then stained with hematoxylin eosin and evaluated by two observers. Data were analyzed using Fisher’s exact test and Mann–Whitney’s U test was used to determine the association between variables. Angelus MTA induced the formation of dystrophic calcifications twice as much as Theracal LC (p < 0.05). The addition of G3 did not affect the greater or lesser occurrence of calcifications (p > 0.05). Theracal LC and MTA plus G3 caused an inflammatory reaction, which was chronic at 15 days and decreased in intensity, almost disappearing after 45 days. Theracal LC, as well as Angelus MTA plus G3, were well tolerated when implanted in the subcutaneous connective tissue of rat. Histologically, no inconvenience was found for the use by direct contact of Theracal LC, and the mixture of MTA with 25% bioactive glass G3, in the tissue of Wistar rats.

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.

Efficacy of Computer-Aided Static Navigation Technique on the Accuracy of Endodontic Microsurgery. A Systematic Review and Meta-Analysis

The aim of this systematic review and meta-analysis was to analyze the efficacy of the computer-aided static navigation technique on the accuracy of root apex location in endodontic microsurgery.

MATERIAL AND METHODS

A systematic literature review and meta-analysis, based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations, of clinical studies that evaluated the apex location rate of the computer-aided static navigation techniques applied to endodontic microsurgery. A total of four databases were consulted in the literature search: Pubmed-Medline, Scopus, Cochrane, and Web of Science. After eliminating duplicated articles and applying the inclusion criteria, seven articles were selected for the qualitative and the quantitative analysis.

RESULTS

The root apex location success rate stated at 96.8% (confidence interval (CI): 93.0-100%) of the cases performed through a computer-aided static navigation technique. The prediction interval ranges from 91.4% to 100%. The meta-analysis did not detect heterogeneity between the combined studies (Q-test = 6.15; p-value = 0.407; I2 = 2.4%). The computer-aided static navigation techniques showed a root apex location success rate 27 times higher than conventional endodontic microsurgery procedures (Q test = 0.80; p = 0.671; I2 = 0%). Three studies of computer-aided static navigation techniques and control group were compared using a random effects model with the Mantel-Haenszel method with a statistically significant odds success ratio of 27.7, with a 95% confidence interval between 11.3 and 68.1 (z test = 7.23; p < 0.0001).

CONCLUSIONS

According to in vitro studies analyzed, endodontic microsurgeries performed through computer-aided static navigation techniques show a high precision.

Prognostic Factors after Endodontic Microsurgery: A Retrospective Study of 111 Cases with 5 to 9 Years of Follow-up

INTRODUCTION

A study was performed of the healing rate of teeth subjected to endodontic microsurgery after a minimum follow-up of 5 years with an analysis of the influence of different pre- and postoperative factors on the outcome.

METHODS

This was a retrospective study of patients subjected to endodontic microsurgery with the use of mineral trioxide aggregate (MTA) for retrograde filling between January 2011 and December 2015. In patients with multiple treated teeth, only 1 random tooth was selected for the statistical analysis. Clinical and radiographic parameters were used to assess healing. Simple binary logistic regression models were used to analyze the influence of patient age and sex, the type of tooth, prior radiographic lesion size, the presence of a post, the type of restoration, and the apical extent of prior filling of the root canal on the endodontic microsurgery success rate. Two calibrated observers evaluated the periapical radiographs on an independent basis.

RESULTS

A total of 111 patients (63.1% women and 36.9% men) were included in the study. Of the 111 teeth analyzed, 90 were classified as healed (mean healing rate = 81.1%). Patient age and sex, the presence of a post, the type of tooth, the type of restoration, and the apical extent of prior filling of the root canal had no significant impact on the outcome. Large lesions (>5 mm) were associated with a lower healing rate than smaller lesions, although the difference was not significant. Anterior teeth had a significantly higher healing rate (93.8% maxillary and 100% mandibular) than molars (70.8% maxillary and 57.1% mandibular) (P < .05). The differences between the anterior teeth and the molars were statistically significant.

CONCLUSIONS

The mean healing rate of teeth subjected to endodontic microsurgery was 81% after 5-9 years of follow-up. The success rate was lower for upper and lower molars than for teeth in the anterior zone, although the sample was small and further studies are needed to establish whether the type of tooth influences the treatment outcome.

Impact of different regenerative techniques and materials on the healing outcome of endodontic surgery: a systematic review and meta-analysis

BACKGROUND

Regenerative techniques are increasingly applied in endodontic surgery, but different materials used in regenerative techniques may have varying impacts on wound healing.

OBJECTIVES

This study evaluated the effects of different regenerative techniques and materials on the outcome of endodontic surgery.

PARTICIPANTS

patients with persistent periapical lesions, treated with root-end surgery.

CONTROL

endodontic surgery without the use of regenerative techniques/materials.

INTERVENTION

endodontic surgery with the use of regenerative techniques/materials.

OUTCOME

combined clinical and radiographic results.

METHODS

PubMed, Web of Science, Embase, SinoMed and the CENTRAL Cochrane were searched up to 10th July 2020, followed by a manual search. Detailed eligibility criteria were applied. Cochrane's risk-of-bias tool 2.0 was used to assess the risk of bias of the eligible studies. Meta-analysis was conducted using RevMan software. Subgroup analyses were performed based on the regenerative materials used in endodontic surgery.

RESULTS

Eleven eligible randomized controlled trials (RCTs) were included in the meta-analysis: two had a low risk of overall bias, and nine had some concerns of overall bias. Generally, the use of regenerative techniques significantly improved the outcome of endodontic surgery (risk ratio [RR]: 0.42; 95% confidence interval [CI], 0.26-0.68; P < 0.001). On subgroup analysis, the use of expanded polytetrafluoroethylene (e-PTFE) membranes alone had no added benefits (RR: 2.00; 95% CI, 0.22-18.33; P = 0.54). The application of collagen membranes or autologous platelet concentrates (APCs) alone was associated with a trend for better outcomes (RR: 0.51; 95% CI, 0.20-1.25; P = 0.14) (RR: 0.55; 95% CI, 0.18-1.71; P = 0.30). The combined use of collagen membranes and bovine-derived hydroxyapatite significantly improved the outcome (RR: 0.35; 95% CI, 0.17-0.75; P = 0.007).

DISCUSSION

This systematic review evaluated the effects of collagen membranes, e-PTFE membranes, APCs and bone grafting materials, providing detailed information about the risks and benefits of using each regenerative technique/material or its combination in endodontic surgery.

CONCLUSIONS

Regenerative techniques improve periapical lesion healing after endodontic surgery. The combined use of collagen membranes and bovine-derived hydroxyapatite may be beneficial as an adjunct to endodontic surgery. In contrast, the positive efficacy of e-PTFE membranes or APCs alone remains doubtful.

Surgical Sealing of Laterally Localized Accessory Root Canal with Resin Containing S-PRG Filler in Combination with Non-Surgical Endodontic Treatment: A Case Report

The spread of root canal infection to surrounding periodontal tissue through accessory root canals reduces the success rate of endodontic treatment. In this case, cone-beam computed tomography revealed a lesion (4 mm from the apex) resulting from an accessory root canal of the maxillary left central incisor. First, non-surgical endodontic treatment was conducted but the sinus tract remained. Surgical preparation of the root cavity was then conducted to remove potentially infected dentin surrounding the accessory root canal. The cavity was filled and the foramen was sealed with resin containing bioactive surface pre-reacted glass (S-PRG) filler. The photopolymerized resin was then contoured and polished. In combination with subsequent supportive non-surgical endodontic treatment, a good clinical outcome with the disappearance of the sinus tract and clinical symptoms such as discomfort and pressure pain and the regeneration of the alveolar bone hanging over the cavity was obtained. In this case, the good clinical outcome may have been due to the dentin-adhesive property and durability of the pre-adhesive system and composite resin. The better biocompatibility of S-PRG fillers presumably facilitated periodontal tissue healing.

Filling ability of three bioceramic root-end filling materials: A micro-computed tomography analysis

This study aimed at evaluating the volume of gaps and voids, and the total porosity percentage of three calcium-silicate-based materials in mandibular molars apicoectomy by Micro-CT analysis. Thirty-three mesial roots of extracted human mandibular molars were instrumented and obturated. The apical 3mm of each root was resected and prepared. Root-end cavities were filled with EndoSequence BC Putty (BC); ProRoot MTA (MTA) and Biodentine (BIO). Samples were scanned using a Micro-CT scanner and the tridimensional images reconstructed. Percentage of gaps (VG%) and of voids (VV%) were obtained. Porosity percentage (Po%) was also assessed. Data were analysed using Student's t-test (P < 0.05). All materials presented gaps and voids. VG% was 2.006 (BC), 1.882 (MTA) and 1.450 (BIO), and VV% was 0.039 (BC), 0.021 (MTA) and 0.024 (BIO) with no statistical difference. Po% were 56.73 (BC), 51.94 (MTA) and 50.45 (BIO), with BC being statistically (P > 0.05) more porous.

Concentrated Growth Factor - Surgical Management of Large Periapical Lesion Using a Novel Platelet Concentrate in Combination with Bone Graft

Although endodontic therapy is typically successful, in approximately 10%-15% of the cases, symptoms can persist or reoccur. Periapical surgery is the preferred treatment of choice in failed root canal therapy, chronic periapical lesion, persistent apical periodontitis, etc., i.e., when conventional treatment modalities fail. Over the past few decades, although the list of indications for endodontic surgery has diminished, there exist definite cases in which the tooth cannot be retained without surgery. This case report, however, sheds light on the incorporation of a novel autologous platelet concentrate-concentrated growth factor (CGF) coupled with an osseograft in surgical endodontic procedure to ensure a swift and successful recovery of the periapical region subjected to extensive lesions. The use of an osseograft combined with CGF has numerous advantages as well due to the formation of sticky bone. There are no articles published in the literature with respect to the potent application of CGF and bone graft (sticky bone) in large periapical lesions to aid in the reparative process. In this case report, the 1-year follow-up radiographs and cone-beam computed tomography showed complete healing of the hard and soft-tissue lesions that conform to achieving repair and regeneration at a rapid rate in extensive periapical lesions.

Healing of Periapical Lesions After Surgical Endodontic Retreatment: A Systematic Review

Background: Surgical root canal retreatment is required when peri-radicular pathosis associated with endodontically treated teeth cannot be treated by non-surgical root canal therapy (retreatment), or when retreatment was ineffective, not feasible or contraindicated. Endodontic failures maybe happen when irritants remain within the confines of the root canal, or when an extra-radicular infection cannot be eradicated by orthograde root canal treatment. Following enhanced microsurgical techniques in the last years, the success rates of surgical root canal retreatment have improved considerably.

Objective: The aim of this systematic review is to gather updated data in regard to the surgical root canal (retrograde) retreatment to heal the periapical lesions.

Materials and methods: The electronic databases PubMed and Google Scholar were searched in this review using specific inclusion and exclusion criteria. The search was performed in June 2019 and updated in November 2019. Among 3900 studies, 10 studies satisfied the eligibility criteria and were included in the review to be analyzed.

Results: The 10 studies showed the importance of surgical root canal retreatment as a treatment option in removing infections within the root canal system and its efficiency in periapical tissue healing. These studies investigated different aspects of healing of periapical lesion after surgical (retrograde) retreatment including success rates, follow-up duration, and updated studies in surgical (retrograde) retreatment.

Conclusions: Surgical root canal (retrograde) retreatment demonstrates its efficiency in reducing the period needed for healing of the periapical lesions in short-term follow-up compared to conventional orthograde retreatment.

Technical note: surgical guide for computer-aided endodontic surgery

INTRODUCTION

CBCT combined to intra-oral scansion are the means to build an endodontic surgical guide to perform an easier and safer access to the apex in endodontic micro-surgery. .

METHODS

A 38-year-old woman presented chronic apical periodontitis, which involved the three roots of 16 that was treated by endodontic therapy several years ago elsewhere. The palatine channel was retreated, the mesio- and disto- buccal roots were instead treated with apicoectomy. A surgical template was printed by a 3D printer to obtain greater precision in the surgical access.

CONCLUSIONS

Endodontic microsurgery has evolved over the years. New tools have been introduced to improve therapy, even if the basic principles have not changed. In fact, according to the literature, it is necessary to cut at least 3 mm of root to be sure of eliminating the anatomical variations and the accessory channels. Several Authors have devoted themselves to creating an endodontic surgical template, some in vitro and others in vivo. The present paper introduces a new method that allows a more conservative osteotomy and greater precision the surgical access. Further investigation are needed to test and improve the effectiveness of the treatment but this technique seems very promising because it is less invasive for the patient and simplifies the work for the dentist who can perform micro-surgery in an easier and faster way.

Detection of Simulated Periradicular Lesions in Porcine Bone by Optical Coherence Tomography

INTRODUCTION

The accurate detection of periradicular lesions located under a nonperforated cortical plate poses a challenge in endodontic microsurgery. Optical coherence tomography (OCT) is a noninvasive imaging method that has been successfully used in many dental applications. In this study, we investigated if spectral-domain OCT (SD-OCT) could be used to determine simulated periradicular lesions.

METHODS

Twenty-eight cavities with different depths were prepared on bone plates obtained from 5 porcine mandibles. Both 3-dimensional SD-OCT imaging and micro-computed tomographic (micro-CT) imaging were used to image the bottom of the air-filled cavity and the cavity filled with soft tissue for comparison. The residual bone thickness under the cavity was measured by SD-OCT and micro-CT imaging and compared using the Pearson correlation.

RESULTS

The air-filled lesions were readily detected; yet, filling of the cavity with soft tissue diminished the appearance of the lesion boundaries in the SD-OCT images. The optical values of residual bone thickness obtained from SD-OCT ranged from 0.14-2.11 mm, which corresponded to the range of 0.26-1.18 mm from micro-CT imaging. A strong correlation was found between the 2 imaging modalities (r = 0.96; range, 0.94-0.98). The slope (1.56) of the linear regression matched the bulk refractive index of bone tissues.

CONCLUSIONS

SD-OCT allows for visualization of the lesion boundaries via intact bone surfaces and may be a promising, practical, and nonirradiating adjunct tool for chairside localization of periradicular lesions in bone.

Morphological Changes of the Root Apex in Permanent Teeth with Failed Endodontic Treatment

OBJECTIVE

To determine the number, shape and diameter of apical foramina as well as changes in root apex morphology of permanent teeth with failed endodontic treatment.

METHODS

Clinical records were collected for teeth diagnosed with posttreatment periapical periodontitis that subsequently underwent endodontic microsurgery. Resected root apices were examined with stereomicroscopy. The number, shape and diameter of apical foramina were recorded. Scanning electron microscopy (SEM) was used to investigate the presence and extent of apical external root resorption and evaluate how it was influenced by sex, age, tooth position, periapical radiolucency size and periapical lesion biopsy results. External root resorption was classified according to site (periforaminal or foraminal), and the extent of resorption was graded as 0, 1, 2 or 3.

RESULTS

A total of 112 teeth with 112 apices were examined. The mean diameter of the main apical foramina was 420.78 µm. The apical foramen was most commonly irregularly shaped (68.39%). The incidence of multiple foramina was 48.21%. SEM revealed that 96.43% of apices had periforaminal resorption (PR) and 94.64% had foraminal resorption (FR). The existence and extent of external root resorption were not correlated with sex, age, tooth position, periapical radiolucency size or periapical lesion biopsy results (P > 0.05).

CONCLUSION

Apical foramina of permanent teeth with failed endodontic treatment were commonly irregularly shaped, with a mean diameter of approximately 420 µm. Nearly half of the samples had multiple foramina. There was a high prevalence of apical external root resorption. A relationship may exist between morphological changes in the root apex and treatment failure.

Influence of Hemostatic Agents in the Prognosis of Periapical Surgery: A Randomized Study of Epinephrine versus Aluminum Chloride

INTRODUCTION

Several variables have been associated with a better prognosis of periapical surgery. The aim of this study was to evaluate the influence of 2 hemostatic agents on the prognosis of periapical surgery at 12 months.

METHODS

A prospective study was designed with 2 randomized parallel groups established depending on the hemostatic agent used: epinephrine or aluminum chloride. The analysis of the hemorrhage control was recorded as 0 (no hemorrhage control), 1 (slight but apparent intermittent bleeding persisted after application of the material), or 2 (complete hemorrhage control). At 12 months, periapical lesion healing was determined clinically and radiologically as success, improvement, or failure.

RESULTS

Ninety-five patients (67 women and 28 men) with periapical lesions involving a single tooth were enrolled in this study; in 45 teeth, epinephrine was used and in 50 teeth aluminum chloride. In the epinephrine group, 28 teeth were classified as successes, 10 as improvements, and 7 as failures. In the aluminum chloride group, 34 teeth were classified as successes, 11 as improvements, and 5 as failures. No statistically significant difference was found.

CONCLUSIONS

The present study found no association between the use of epinephrine or aluminum chloride as hemostatic agents on the prognosis of periapical surgery. The efficacy of hemostatic agents at the time of surgery showed no relationship with the healing outcome.

Adaptation of mineral trioxide aggregate to dentine walls compared with other root-end filling materials: A systematic review

This systematic review analysed the literature comparing marginal adaptation of mineral trioxide aggregate (MTA) with other filling materials in root-end cavities. The PubMed, Ovid, Web of Science, SCOPUS, and Cochrane library databases were searched using appropriate keywords related to root-end filling materials and adaptation. Of 38 articles assessed, 20 met the inclusion criteria. No in vivo study was identified. In 10 studies, MTA gave the best marginal adaptation results, but no significant differences were found between MTA and any of the tested filling materials in seven studies. There was great variability in the study designs including analysed surface, unit of gap measurement and magnification amount during analysis. On the basis of available evidence, MTA presented good marginal adaptation to dentine walls. This review identified the need for the development of standardised methods to evaluate the adaptation property of root-end filling materials in ex vivo studies as well as in clinical studies evaluating outcome.

Endodontic Surgery of a Deviated Premolar Root in the Surgical Orthodontic Management of an Impacted Maxillary Canine

Maxillary canine impactions are of multifactorial etiology. The incidence of maxillary canine impaction ranges from 1% to 4%. One of the reasons for canine impaction might be a deviated premolar root. This report describes surgical-orthodontic extrusion of an upper canine that occurred only after the endodontic surgery treatment of the adjacent deviated premolar root. Orthograde endodontic treatment followed by endodontic surgery with retrograde filling of the deviated premolar root was performed to obtain a surgical-orthodontic extrusion of the upper canine. A female patient, aged 15 years, with a class I molar relationship was referred to continue the orthodontic therapy. Although a correct surgical-orthodontic extrusion with adequate anchorage was carried out, the maxillary left canine had not erupted. Radiographic examination showed a deviated palatal root of the adjacent maxillary first premolar in the canine eruption path. Root canal filling followed by endodontic surgery of the first premolar deviated root has led to rapid progression of the canine and its placement in the arch in just 3 months. A multidisciplinary management involving endodontic treatment, endodontic surgery, and surgical-orthodontic extrusion could be considered a successful approach in the maxillary impacted canine cases in which adjacent premolar root is deviated. Long-term radiographic follow-up (6 years) indicated stable periodontal health of the canine and premolar without the presence of root resorption.

Guided tissue regeneration in endodontic surgery by using a bioactive resorbable membrane

INTRODUCTION

Guided tissue regeneration is a valuable technique available to the endodontist because the quality, quantity, or extent of bone loss cannot be visualized by the surgeon until the tissue is reflected and the surgical site is exposed.

METHODS

After repeated attempts at nonsurgical treatment, a patient with a recurring sinus tract over the distobuccal root of an upper molar ultimately had the distobuccal root resected, leaving a 10 × 10 mm bony defect. This dehiscence was filled with freeze-dried bone and covered with a flexible and absorbable bioactive membrane that was new to endodontics.

RESULTS

Healing was uneventful, and bone regeneration was rapid and extensive as observed at the time of a second surgery just 5 months later. This can be attributed at least in part to the use of the bioactive membrane that contains an array of growth factors that enhance cell proliferation, inflammation, recruitment of progenitor cells, and metalloproteinase activity.

CONCLUSIONS

The use of the bioactive membrane in endodontic surgery should be considered to best restore the attachment apparatus to the tooth and prevent the downgrowth of a long junctional epithelium. The endodontist's attention must not be limited to the apical region alone.

Surgical management of invasive cervical resorption using resin-modified glass ionomer cement

Invasive cervical resorption is an external resorption that begins below the epithelial attachment. It is caused primarily by dental trauma, orthodontic treatment, or dental bleaching. This case report involved an invasive Class III cervical resorption resulting from trauma to the superior right central incisor. Root canal treatment was followed by surgical intervention. The resorptive defect was debrided, and part of the tooth was restored with resin-modified glass ionomer cement. Postoperative follow-up revealed complete healing and healthy gingival attachment.

Cone-beam computed tomography analysis of the vestibular surgical pathway to the palatine root of the maxillary first molar

OBJECTIVE

The aim of this study was to evaluate the anatomical distance between apices of the palatine root of the maxillary first molars to the buccal bone plate to identify the vestibular surgical pathway in a Turkish adult population using cone-beam computed tomography (CBCT) images.

METHODS

CBCT scans of 107 (48 male and 59 female) patients were retrospectively analyzed. The overall mean age was 38.6 years. The distance between the vestibular cortex and vestibular side of the palatine root was measured for 192 maxillary first molars both on axial images parallel to the palatal plane and on reformatted cross-sectional images. A Pearson's chi square test and Mann-Whitney U-test were performed to evaluate differences among age, localization, and measurements. Differences were considered statistically significant at P<.05.

RESULTS

The mean distance between the buccal cortex and the buccal side of the palatine root of the superior first molar in both male and female patients was 10.13 and 9.70 mm, respectively. The incidence of interposition of the lateral recess of the maxillary sinus between the roots was 42.2% and 49% in men and women, respectively. Statistically significant sex-related differences were found in the vestibular surgical pathway (P<.05).

CONCLUSIONS

For precise planning of endodontic surgery, it is crucial to determine the exact dimensions and location of the periapical lesion, as well as its relationship with the roots and other neighboring anatomical structures. CBCT can be a powerful tool for the evaluation of surgical cases in three dimensions with less ionizing radiation and better avoidance of complications during surgery.