Is Augmented Reality Technology Effective in Locating the Apex of Teeth Undergoing Apicoectomy Procedures?

This study seeks to assess the accuracy of apical location using an augmented reality (AR) device with a free-hand method. Sixty (60) osteotomy site preparations were randomly assigned to one of two study groups: A. AR device (AR) (n = 30), and B. conventional free-hand method (FHM) (n = 30). Preoperative CBCT scans and intraoral scans were taken and uploaded to specialized implant-planning software to virtually plan preparations for the apical location osteotomy sites. The planning software was then used to automatically segment the teeth in each experimental model for their complete visualization using the AR device. A CBCT scan was carried out postoperatively after conducting the apical location procedures. The subsequent datasets were imported into therapeutic software to analyze the coronal, apical, and angular deviations. The Mann-Whitney non-parametric test was used. There were no statistically significant differences identified at the coronal (p = 0.1335), apical (p = 0.2401), and angular deviations (p = 0.4849) between the AR and FHM study groups. The augmented reality technique did not show a statistically significant accuracy of osteotomies for apical location when compared with the conventional free-hand method.

Healing and Spontaneous Realignment of Displaced Roots With Periapical Granuloma After Microsurgical Endodontic Treatment (Three Years' Follow-up): A Case Report

Endodontic therapy aims to treat or prevent apical periodontitis, a condition characterized by inflammation of the periapical tissues at the apex of the tooth root. This case study demonstrates the successful nonsurgical and surgical management of a large periapical lesion involving the lower central incisors with root displacement induced by a periapical granuloma. A patient was referred from the maxillofacial department for endodontic treatment due to persistent pain and swelling in the lower anterior region started two months ago. Upon arrival, a clinical examination and radiographic assessment were performed using cone-beam computed tomography (CBCT). The CBCT scan revealed a significant radiolucent area measuring (10x8) mm extending from the lower left lateral incisor to the right central incisor. The lower left central incisor was necrotic and tender to palpation and percussion. A nonsurgical root canal was performed followed by an apicectomy using mineral trioxide aggregate (MTA) to facilitate healing of the periapical lesion. Histopathological examination of the lesion confirmed the diagnosis of periapical granuloma. At follow-up 1, 2, and 3 years' visits, the periodontal assessment was performed and found to be free of pain upon percussion or palpation. No other clinical or radiological signs or symptoms were identified except for a small radiolucent area mesially adjacent to the root of the lower left central incisor. The development of materials such as MTA has significantly improved the prognosis of cases with large periapical lesions. In this case, healing and spontaneous realignment of the root were observed after three years.

Unraveling the Enigma of Managing a Large Periapical Lesion: A Case Report

This case report documents the diagnosis and successful management of a substantial periapical lesion located in the lower left region of the jaw. The patient presented with clinical symptoms indicative of periapical pathology, and radiographic examination revealed an extensive radiolucent lesion. The chosen treatment approach involved endodontic intervention coupled with surgical decompression, leading to the resolution of the lesion and restoration of oral health. This case underscores the significance of an accurate diagnosis and a multidisciplinary treatment approach in addressing large periapical lesions.

Effect of Endo-Z bur or Bladesonic ultrasonic tip on the adaptation of filling material. A micro-CT study

This study aimed to evaluate the effect of apicoectomy performed with a bur or an ultrasonic tip on the adaptation of the filling material to root canal dentin. Twenty human mandibular incisors were selected and prepared with a ProDesign Logic system up to diameter 40/.05. The root canals were filled with Bio-C Sealer (Angelus, PR, Brazil) using the single cone technique and were stored at 37ºC and 95% relative humidity for 7 days. After this period, the apicoectomy of the 3 millimeters of the root apex was performed using Endo-Z bur (Dentsply Sirona) or Bladesonic ultrasonic tip (Helse Ultrasonic, Santa Rosa de Viterbo, Brazil) (n=10). The specimens were scanned by micro-computed tomography (micro-CT; SkyScan 1176) with a voxel size of 8.74 µm after obturation and after apicoectomy. The percentage of voids at the interface between the filling material and the root canal wall was evaluated in the apical 4 mm of the root after apicoectomy, besides the time cutting to both devices. The data obtained were submitted to paired and unpaired t-tests (α = 0.05). Endo-Z and Bladesonic increased the percentage of voids between the filling material and the dentin after apicectomy (p<0.05), and they were similar (p>0.05). Endo-Z has a shorter time to perform apicoectomy compared to Bladesonic (p<0.05). Apicectomies with Endo-Z or Bladesonic could harm the material/dentin interface, while the Endo-Z bur was faster than the Bladesonic ultrasonic tip.

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.

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.

Management of a Radicular Cyst in Anterior Maxilla With Endosurgical Intervention Along With Use of Mineral Trioxide Aggregate (MTA) and Bone Graft: A Case Report

Radicular cysts are the most common cystic lesions that affect the jaws, which, though mostly asymptomatic, can be seen radiographically as an oval or pear-shaped unilocular radiolucency in the periapical region. Nonsurgical root canal procedures and periapical surgery followed by placement of bone substitute and bioceramic root-end filling material is generally the treatment of choice. This case report highlights the endosurgical management of long-standing trauma that led to a radicular cyst with respect to three maxillary anterior teeth in a young adult. The clinical and radiographic examination led to a provisional diagnosis of a radicular cyst, which was confirmed by biopsy. Non-surgical root canal treatment was performed with Mineral Trioxide Aggregate (MTA) as the apical barrier and surgical enucleation of the cyst was performed followed by placement of hydroxyapatite bone graft. Follow-ups till two years were done, which revealed the successful management of the case.

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.

Management of Discoloured Anterior Teeth With Radicular Cyst: A Case Report

Dental trauma often has tooth discoloration and periapical lesion as its sequelae. Intracoronal bleaching restores the aesthetics, while a retrograde approach is required for non-healing lesions. A patient with discolored teeth, draining sinus, tenderness and a periapical lesion on the radiograph was treated initially with conventional root canal therapy and walking bleach technique. After four months, the sinus tract reappeared and on cone-beam computed tomography (CBCT) examination, a large periapical lesion with loss of buccal cortical plate was seen. A minimally invasive retrograde cystic enucleation, apicectomy, and filling with biodentine were then performed. The defect area was filled with synthetic nanocrystalline hydroxyapatite granules combined with platelet-rich-fibrin. Follow-ups after one, three, and six months were taken. The six-month CBCT revealed complete bone healing. Non-vital bleaching yields acceptable cosmetic results. Additionally, if the conventional procedures are not successful in treating radicular cyst, apical surgery must be the ultimate choice.

Treatment of an ossifying fibroma of the mandible with endodontic microsurgery and grafting with a biphasic calcium sulfate material: a case report

A significant percentage of lesions of endodontic origin require surgical management due to the possible diagnosis of odontogenic cysts and tumors in the maxilla and mandible. Ossifying fibroma is a benign fibro-osseous lesion that typically presents as a painless, slow-growing, and expansile lesion that appears as a well-demarcated lesion with a variable degree of internal calcification on radiography. Treatment results in a large osseous defect, utilization of a graft to fill the void accelerates healing and prevents complications that may result from failure to fill by the host response.

CASE PRESENTATION

Following endodontic surgery placement of osseous graft material via Guided Tissue Regeneration to fill the defect aids to accelerate fill of the defect on a healthy 26-year-old female patient. A case discussing the one-step treatment of an ossifying fibroma of the anterior part of the mandible following endodontic microsurgery with associated retrograde fill of the apex, then site grating with biphasic calcium sulfate (Bond Apatite®) used in regeneration of the osseous defect related to the lesion and resulting surgery.

CLINICAL DISCUSSION

Histologically, the ossifying fibroma is dominated by connective tissue containing cell rich areas with a few fragments of fibrosis. Moreover, in the connective tissue numerous small fragments of spongy and compact bone with areas of partial necrosis present and a significant number of inflammatory cells are observed. Surgical removal of the cyst with thorough curettage of the osseous walls and grafting of the defect provides predictable healing and the desired clinical results sought. Utilization of the biphasic calcium sulfate graft material allows the elimination of the need to overlay the area with a membrane before the flap due to its hard set and the prevention of soft tissue ingrowth into the graft material during the healing phase. Additionally, the hard set of the material allows tenting of the area to maintain the desired volume and ridge contour. Conversion of the graft material depending on the volume placed to host bone occurs over a 3-6 month period.

CONCLUSION

The case report presented, as well as the authors experience mimics the literature on biphasic calcium sulfate in its use as an osseous graft material and is an effective method for the repair of osseous defects that result from the removal of tumors and cysts of the maxilla and mandible. Treatment of an ossifying fibroma is an ideal application of the use of this biphasic calcium sulfate material allowing tenting of the surgical site over the defect created after cyst removal without the need for resorbable collagen membranes. This simplifies its use and decreases material costs that may hamper patient acceptance of treatment without a decrease in expected clinical results.

Periradicular surgery: a longitudinal registry study of ten-year outcomes and factors predictive of post-surgical extraction

AIM

This historical prospective cohort study of the adult population of Sweden is based on data from a national registry: the primary aim was to evaluate the long-term survival of teeth after periradicular surgery. A secondary aim was to identify factors predictive of extraction within 10 years of registration of periradicular surgery.

METHODOLOGY

The cohort consisted of all individuals who had undergone periradicular surgery to treat apical periodontitis, as reported to the Swedish Social Insurance Agency (SSIA) during 2009. The cohort was followed until December 31, 2020. Subsequent registrations of extractions were collected for Kaplan-Meier survival analyses and survival tables. The patients' sex, age, dental service provider and tooth group were also retrieved from SSIA. Only one tooth per individual was included in the analyses. Multivariable regression analysis was used and P < 0.05 was considered statistically significant. The reporting guidelines STROBE and PROBE were followed.

RESULTS

After data cleaning, and exclusion of 157 teeth, 5 622 teeth/individuals remained for analysis. The mean age of the individuals at the time of the periradicular surgery was 60.5 years (range 20-97, standard deviation 13.31); 55% were women. At the end of the follow-up, that is, up to 12 years, a total of 34.1% of the teeth had been reported as extracted. The multivariate logistic regression analysis, based on follow-up data at 10 years after registration of the periradicular surgery, included 5 548 teeth, of which 1 461 (26.3%) had been extracted. Significant associations between the independent variables tooth group and dental care setting (both P < 0.001) and the dependent variable extraction were found. The highest odds ratio (OR) for extraction applied to tooth group: compared to maxillary incisors and canines, mandibular molars were at greatest risk of extraction (OR 2.429, confidence interval 1.975-2.987, P < 0.001).

CONCLUSIONS

After periradicular surgery in predominantly elderly people in Sweden, approximately three quarters of the teeth are retained over a 10-year period. The type of tooth is associated with extraction: mandibular molars are at greater risk of extraction than maxillary incisors and canines.

Comparative SEM study of the marginal adaptation of MTA and Biodentine after apical resection (in vitro study)

INTRODUCTION

Successful periapical surgery requires appropriate root resection, preparation, and adequate sealing.

AIM

The aim of the present study was to assess the marginal adaptation of MTA and Biodentine after apical resection with an Er:YAG laser and a diamond turbine bur using a scanning electron microscope (SEM).

MATERIALS AND METHODS

The crown part of forty-eight extracted single-root human teeth was removed, and the root canal length of 15 mm was standardized. The root canals were prepared using rotary Ni-Ti Revo-S files up to an apical stop - AS40 and filled with MTA Fillapex and gutta-percha points (cold lateral condensation). The teeth are divided into 2 main groups: group 1 (n=24) after apical resection with a turbine bur, ultrasonic preparation of the retrograde cavity at 3 mm depth and retrograde obturation with Biodentine and MTA; group 2 (n=24) after apical resection with an Er:YAG laser, ultrasonic preparation of the retrograde cavity at a depth of 3 mm and retrograde obturation with MTA and Biodentine. A SEM was used for assessment of the marginal adaptation of the material to the root dentin. The data was entered into and analyzed with IBM SPSS Statistics 22.0.

RESULTS

In the group with apical resection with a turbine bur, a statistically significant difference in the gap size between the material and dentin was found in both materials we studied (MTA and Biodentine). The higher mean value was in MTA (1.72 µm), in Biodentine it was 1.08 µm. In the group with apical resection with Er:YAG laser, no statistically significant difference in the gap size between the material and dentin was found in both studied materials: MTA - 1.88 µm, Biodentine - 1.32 µm.

CONCLUSIONS

In the present study, MTA and Biodentine showed good sealing capabilities after apical resection. Biodentine displayed better marginal adaptation when resecting the root tip using a turbine bur. The Er:YAG laser-assisted apical resection shows sealing of the open dentinal tubules around the resected root surface.

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.

Extraoral Root-End Resection May Promote Pulpal Revascularization in Autotransplanted Mature Teeth-A Retrospective Study

Tooth germ autotransplantation of open apices of the teeth exhibits high pulpal healing rates, whereas that of mature permanent teeth normally causes irreversible pulpal necrosis. Extraoral root-end resection (EORER) during transplantation may promote pulpal revascularization (PRV) in transplanted mature teeth and reduce endodontic treatment requirement. This study compared the primary outcomes of survival rates, PRV, and root resorption and determined relevant confounders in autotransplanted mature and immature teeth. The medical charts of consecutive patients who underwent tooth autotransplantation between January 2017 and March 2021 were evaluated. Teeth with a documented follow-up of at least 1 year were included. During the study period, 59 teeth were transplanted in 44 patients. Overall, 2 teeth were excluded owing to missing data; 57 teeth were analyzed, including 25 mature teeth additionally treated with EORER. After a mean follow-up of 21.2 ± 16.1 months, no significant differences in primary outcomes were detected. Fifty-five teeth remained in situ (96.5%), and radiological signs of root resorption were detected in 9/57 teeth (15.8%). PRV was positive in 54/57 teeth (94.7%). Surgical duration and PRV failure were significantly associated with high incidences of root resorption. Mature teeth autotransplantation with EORER yielded similar results to immature teeth autotransplantation and is a feasible treatment option. Long surgery and failed revascularization increased root resorption rates. More factors should be evaluated in larger trials with longer observation periods.

Management of transverse root fractures in dental trauma

The management of complex dental trauma can be modulated according to the emergencies that may arise over time. Clinical management of transverse root fractures may require different therapies based on situations, such as delay and error in the treatment of an avulsion trauma associated with apical third root fracture, patient's poor compliance, or external and internal root resorption. The primary aim of this article was to review studies regarding root fractures in the permanent dentition and root fracture management. The secondary aim was to present the inflammatory reaction and the complications (i.e., infections) that may occur if the International Association for Dental Traumatology (IADT) guidelines are not followed. In addition, a scenario is devised in which endodontic surgery, despite the baseline patient's conditions and negative prognosis, can help to inhibit the inflammatory root resorption and allow the preservation of soft and hard tissues within a long follow-up from the injury, for the purpose of demonstrating the next possible implant-prosthetic rehabilitation.

Extraction and replantation of a periapically infected tooth

At times, an infected tooth that may be deemed unrestorable may be salvaged by atraumatic removal, an in-hand apicoectomy and retrograde seal, then replantation. This patient was referred to this author for an extraction and implant treatment of the maxillary left second premolar. After a discussion, the patient preferred to salvage the tooth if possible. The tooth was successfully atraumatically removed, and an in-hand apicoectomy and retrograde amalgam seal was placed. The tooth was immediately replaced into its socket and was stable. The occlusal surface was flattened to prevent and off axial loading. A bis-acryl brace was applied to the facial and lingual aspect to prevent an overload while the tooth was healing. The patient was admonished to maintain a soft diet. After 3 weeks, the braces were removed, and the tooth was found to be stable. After 8 weeks, the tooth was asymptomatic, and the patient was able to revert to her normal diet without pain. While extraction, placing an apical seal and replantation of teeth is not a new modality; nonetheless, clinicians may need to be reminded of this procedure to increase the number of options presented to patients.

Adjunctive use of antimicrobial photodynamic therapy in the surgical treatment of periapical lesions: a case series

BACKGROUND

Antimicrobial photodynamic therapy (aPDT) is being used in endodontics to improve orthograde root canal disinfection as an adjunct to standard treatments. Conversely, evidence concerning the application of aPDT in retrograde endodontic surgery is limited. Thus, the aim of the present study was to provide additional data regarding the use of aPDT in the surgical endodontic treatment of periapical lesions.

METHODS

A total of 25 consecutive patients presenting teeth with periapical radiolucency eventually associated with clinical signs and symptoms of apical periodontitis were included. Following access flap completion, osteotomy, mechanical debridement, root apical third resection, and preparation of the root-end cavity, aPDT was applied to decontaminate the surgical site using phenothiazine chloride dye at a concentration of 10 mg/mL and irradiation with a hand-held 100-mW diode laser with a wavelength of 660 ± 10 nm. At the latest follow-up visit, healing was evaluated as successful, uncertain, or failure according to well-established clinical and radiological criteria.

RESULTS

Overall, 31 periapical lesions were treated with aPDT. Healing proceeded uneventfully. The mean follow-up time was 36.19 months, with times ranging from 12 to 85 months. A total of 25 (80.65%) cases were classified as successful, 5 (16.13%) as uncertain, and only one (3.22%) as failure. Irrespective of the treatment outcome, all treated teeth were still functional, with no symptoms reported by the patients.

CONCLUSION

aPDT as an adjunctive treatment modality in the surgical endodontic treatment of periapical lesions showed promising medium-term results associated with preservation of all diseased teeth.

A Comparative Analysis of the Piezoelectric Ultrasonic Appliance and Trephine Bur for Apical Location: An In Vitro Study

To compare and contrast the accuracy of piezoelectric ultrasonic insert (PUI) and trephine bur (TB) osteotomy site preparation techniques for apical location. (1) Material and methods: A total of 138 osteotomy site preparations were randomly distributed into one of two study groups. Group A: TB technique (n = 69) and B: PUI technique (n = 69). A preoperative cone-beam computed tomography scan and an intraoral scan were performed and uploaded to implant-planning software to plan the virtual osteotomy site preparations for apical location. Subsequently, the osteotomy site preparations were performed in the experimental models with both osteotomy site preparation techniques and a postoperative CBCT scan was performed and uploaded into the implant-planning software and matched with the virtually planned osteotomy site preparations to measure the deviation angle and horizontal deviation as captured at the coronal entry point and apical end-point between osteotomy site preparations using Student’s t-test statistical analysis. (2) Results: The paired t-test found statistically significant differences at the coronal entry-point deviations (p = 0.0104) and apical end-point deviations (p = 0.0104) between the TB and PUI study groups; however, no statistically significant differences were found in the angular deviations (p = 0.309) between the trephine bur and piezoelectric ultrasonic insert study groups. (3) Conclusions: The results showed that the TB is more accurate than the PUI for apical location.

Impact of Periodontal Attachment Loss on the Outcome of Endodontic Microsurgery: A Systematic Review and Meta-Analysis

Background and Objectives: Endodontic microsurgery (EMS) aims to eradicate the sources of infection once the apical root resection removes most of the infected anatomical structures and repairs potential procedural errors in the apical region. An endodontic-periodontal lesion yields a pathological communication between the pulp and the periodontium. The purpose of this systematic review and meta-analysis is to evaluate the impact of periodontal attachment loss on the outcome of teeth submitted to EMS. Materials and Methods: PRISMA guidelines were followed. An electronic search was performed in EBSCOhost, Embase and PubMed databases with the following search key: (“endodontic microsurgery” AND “outcome”). No filters were used concerning the year of publication or language. Only randomized clinical trials, prospective and retrospective clinical studies in humans, with a minimum one-year follow-up, defined clinical and radiographic outcome criteria and estimable success rate for endodontic-periodontal lesion were included. Statistical analysis was performed using OpenMeta[Analyst] software. Results: Of a total of 113 articles, 34 were selected for full-text reading after duplicates deletion and title and abstract analysis. Thirteen and six studies were included in the systematic review and meta-analysis, respectively. A total of 2775 pooled teeth were submitted to EMS, of which 492 teeth and 4 roots had periodontal involvement. According to the qualitative analysis, success rates of the endodontic-periodontal group ranged from 67.6% to 88.2%. Meta-analysis revealed that the absence of periodontal attachment loss was predictive of a higher likelihood of success with an odds ratio of 3.14. Conclusions: Periodontal attachment loss presents a risk factor for EMS outcome. Although endodontic-periodontal lesions were associated with lower success rates considering a 1 to 10 years follow-up period, long-term successful prognosis following EMS has been reported, therefore presenting a fully valid and viable therapeutic option for the management of this type of lesions.

Guided endodontic microsurgery in apicoectomy: a review

The purpose of this review was twofold. The first aim was to show predictable protocols of guided endodontic microsurgery (EMS) and to describe its clinical outcomes. The second aim was to verify the accuracy of this technique compared to the traditional pathway. An electronic search of publications was established from two electronic databases, Cochrane and PubMed, by two independent researchers. The search strategy used a combination of controlled vocabulary and free-text words. Inclusion and exclusion criteria were defined by the authors before the start of the study. Inclusion criteria were: all studies published in English language; studies in vivo on humans; human cadaver studies; studies analyzing guided surgery in apicoectomy. The initial search yielded 67 citations, of which 10 were included. The studies included in this review analysis have shown two different technique both for digitization of dental arch and for surgical procedures too. Guided endodontic micro-surgery is a more predictable technique with less intra-operative and post-operative complications compared to the "freehand" technique and this procedure has shown a greater accuracy.

Decompression strategy for critical-sized lesions: A case series and literature review

Critical-sized lesions are defined as the smallest sized intraosseous wound in a particular bone that will not heal spontaneously during the lifetime of that animal. These critical-sized entities pose a unique challenge in endodontics, where these lesions are most likely cystic, with dimensions extending over 10 mm. This paper describes a structured methodology to treat such cases whilst also highlighting inconsistencies and variability between practitioners regarding management of critical-sized lesions. The case series demonstrates that non-surgical root canal therapy followed by surgical decompression may be the treatment of choice for such pathosis. A 16 gauge nasogastric tube was used as a decompression device and sutured to surrounding mucosa. Healing was evaluated using both two- and three-dimensional radiographs. Decompression of critical-sized lesions would appear to be a reliable, conservative and an altogether complete procedure that may not warrant second-stage surgery.

Ablation Precision and Thermal Effects of a Picosecond Infrared Laser (PIRL) on Roots of Human Teeth: A Pilot Study Ex Vivo

BACKGROUND/AIM

Picosecond infrared laser (PIRL) was investigated regarding its possible therapeutic application in cutting dental roots.

MATERIALS AND METHODS

Extracted human teeth were processed in the root area by laser ablations followed by histological evaluation. Dentin adjacent to the cutting surface was evaluated morphometrically.

RESULTS

PIRL produced clearly defined cutting boundaries in dental roots. At the bottom of the cavity, the ablation surface became slightly concave. Heat development in this scantly hydrated tissue was considerable. We attributed the excess heating effects to heat accumulation due to multiple pulse overlap across a limited scan range imposed by tooth geometries.

CONCLUSION

Defined areas of the tooth root may be treated using the PIRL. For clinical translation, it would be necessary to improve beam delivery to facilitate beam steering for the intended oral application (e.g. by using a fiber) and identify optimal repetition rates/scan speeds combined with cooling techniques to minimize accumulated heat within ablation cavities.

Accuracy and efficiency of guided root-end resection using a dynamic navigation system: a human cadaver study

AIM

To determine and compare the accuracy and efficiency of a dynamic navigation system (DNS) with a freehand (FH) technique when conducting root-end resection in a human cadaver model.

METHODOLOGY

Forty roots in cadaver heads were included and divided into two groups: DNS (n = 20) and FH (n = 20). Cone beam computed tomography (CBCT) scans of all teeth were taken. The drilling path and depth were planned virtually to using the X-guide software (X-Nav Technologies, Lansdale, PA, USA). Osteotomy and root-end resection were done under navigation in the DNS group, and freehand under the dental operating microscope in the FH group. Post-operative CBCTs were taken. Linear deviations, angular deflection, time of operation and number of mishaps were compared with determine the accuracy and efficiency. Shapiro-Wilk, one-way ANOVA and Fisher exact tests were used (P < 0.05).

RESULTS

Linear deviations, angular deflection and operation time were significantly less in the DNS group (P < 0.05). The number of mishaps was not different between the two groups (P > 0.05). Subgroup analyses revealed that the distance of >5 mm from buccal cortical plate was significantly associated with lower accuracy, increased operation time and greater incidence of mishaps in the FH group (P < 0.05), but not in the DNS group.

CONCLUSIONS

The dynamic navigation system was more accurate and more efficient in root-end resection in a cadaver model than the freehand technique. The distance of the roots from the buccal cortical plate had a significant negative impact on the accuracy and efficacy of the root-end resection procedure when using the freehand technique. The dynamic navigation system has the potential to be a safe and reliable technological addition to endodontic microsurgery.

Scanning electron microscopy analysis of marginal adaptation of mineral trioxide aggregate, tricalcium silicate cement, and dental amalgam as a root end filling materials

The aim of this research was to examine marginal adaptation of three root end filling materials mineral trioxide aggregate (MTA), Biodentine and amalgam. Ninety single-rooted extracted human teeth of the maxillary intercanine sector were used in the study. After the endodontic treatment and retrograde preparation, teeth were divided into three groups, depending on the root-end filling material. Teeth were cut in longitudinal manner. Measurements of the total width of the marginal gap in micrometers were performed using scanning electron microscopy. The results showed that MTA and Biodentine have better marginal adaptation compared to amalgam expressed through the mean value of the measured edge crack, however without significant difference (p > .05). Mean value of the measured edge crack in Group 1 (MTA) was 8.17 μm, in Group 2 (Biodentine) 8.53 μm, and in Group 3 (amalgam) 9.13 μm. All tested materials show a satisfactory degree of marginal adaptation, but MTA and Biodentine proved to be superior to amalgam.

Resolution of a Cystic Endodontic-Periodontal Lesion Utilizing Combined Apicoectomy And Guided Tissue Regeneration: A Case Report

INTRODUCTION

Endodontic-periodontal combined lesions pose a treatment challenge for clinicians, especially when the lesion is persistent and does not show signs of healing after initial endodontic treatment. This case report describes interdisciplinary management of a non-healing combined endodontic-periodontal lesion related to a peri-apical cyst, through a combined approach of apicoectomy and guided tissue regeneration (GTR) with enamel matrix derivative (EMD). Most documented cases have been treated in a sequential manner, with minimal literature present on the effects of a combined approach utilizing EMD for the treatment of these lesions.

CASE PRESENTATION

A 72-year-old male patient presented with an endodontic-periodontal lesion at tooth #31 initially treated with nonsurgical root canal therapy. The lesion was not responsive to initial endodontic treatment. The patient was informed of questionable prognosis, however wished to save the tooth. Tooth #31 was treated via a combination approach of apicoectomy with bioceramic putty retrograde filling, followed by GTR of the defect using allograft, EMD, and resorbable barrier membrane. The lesion was biopsied and diagnosed as a periapical cyst. Clinical and radiographic examination at 1 year showed resolution of lesion, reduction in probing depths, and good bone fill of the defect.

CONCLUSION

Traditionally, endodontic-periodontal lesions, which were not responsive to initial therapy, would be given a questionable prognosis and be extracted. This case demonstrates that non-healing, peri-apical lesions may be cystic in nature and effectively managed utilizing a combined approach, with apicoectomy and GTR with EMD, to produce a stable outcome.

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.

Streamlining and simplification of surgical stent fabrication for micro-endodontic surgery

Surgical stents allow clinicians to undertake micro-endodontic surgical procedures with an increased level of accuracy. When planned in combination with cone-beam computed tomography (CBCT) radiographic imaging, surgical stents can help accurately determine the point of entry of the surgical drill, minimise the size of the osteotomy, ensure accurate resection of the root/s and avoid vital anatomical structures. Fabrication of surgical stents can, however, be a complex and long-drawn-out process, adding to the cost of the surgery. This case report presents a relatively easy method of fabricating a surgical guide and showcases the benefits of a planned surgical guide in managing a periapical pathology with close proximity to the mental nerve canal.

Perforation of the maxillary sinus floor during apical surgery of maxillary molars: A retrospective analysis using cone beam computed tomography

This retrospective analysis assessed a possible correlation of perforation of the maxillary sinus floor during apical surgery of maxillary molars and the distances from the treated apices/periapical radiolucencies to the sinus floor. The material included 168 apical surgeries of maxillary first or second molars performed from 1999 to 2016. In 22 (out of 33) perforation cases, a preoperative cone beam computed tomography (CBCT) was available. These cases were defined as the test group. From the pool of operated cases without sinus floor perforation, matching cases - that is, same treated tooth, similar age and same gender - were selected as a control group (N = 26). Mean linear distances from root apices or radiolucencies to sinus floor were significantly shorter in the test group compared to the control group. In conclusion, perforation cases were significantly closer to the sinus floor than cases without perforation.

Incidence of retrograde peri-implantitis in sites with previous apical surgeries: A retrospective study

BACKGROUND

Retrograde peri-implantitis (RPI) is a rapidly progressing periapical infection that forms around the implant apex. It is usually associated with sites adjacent to teeth with apical lesions; previous endodontic failures, retained root fragments, etc. This study aimed to study the incidence of RPI in sites with a history of apical surgeries.

METHODS

Patients with sites treated for both apicoectomy and implant placement presenting to the University of Michigan School of Dentistry from 2001 to 2016 were screened. A total of 502 apicoectomies were performed, only 25 of these fit the predetermined eligibility criteria and were thus included in this retrospective analysis.

RESULTS

Implants that were placed in sites with a previous apical surgery had a cumulative survival rate of 92%. The incidence of peri-implantitis was 8%, while the incidence of RPI was 20%. There was an increased trend for RPI in cases where the cause of extraction was persistent apical periodontitis (35.7%), but this increase didn't reach the level of statistical significance (P = 0.061).

CONCLUSION

Implants placed in sites with previous apical surgery are not at an increased risk of implant failure or RPI.

Digitally planned root end surgery with static guide and custom trephine burs: A case report

INTRODUCTION

Apicoectomy is an endodontic surgical intervention that requires high precision. The computer-assisted static guided approach has proven to increase the precision of dental implantation in a significant manner. The authors sought to transfer this precision to root-end resection with the use of custom designed trephine burs manufactured specifically for use in targeted endodontic microsurgery.

METHODS

A set of custom bone trephines were designed and manufactured, then their digital models were integrated into an already existing implant surgical planning software, in cooperation with the software developer. Apicoectomy was performed in an actual case with the help of the new system.

RESULTS

It has become possible to plan root end removal in the virtual space and to manufacture 3D printed static surgical guides to help the execution of the surgery. A patient with persistent periapical lesion was successfully treated without complication. The 6-month follow-up found uneventful healing.

CONCLUSION

The presented system is a step toward a standardized digital system and workflow dedicated to guided endodontic surgery.

Endodontic management of an autotransplanted mandibular third molar: A simplified approach

BACKGROUND AND OVERVIEW

In this case report, the authors aim to review the standard protocols for endodontic treatment of autotransplanted molars and report on the 5-year follow-up of a clinical transplantation case.

CASE DESCRIPTION

The authors transplanted a mandibular third molar into the position of the adjacent second molar. The authors performed extraoral apicoectomy and retrograde restoration after atraumatic extraction of the donor tooth and before transplantation. The authors did not perform conventional orthograde root canal treatment after transplantation. The patient was followed up 5 years after the autotransplantation. Results of follow-up radiography showed a regular root surface without evidence of periapical lesions or root resorption.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

If appropriate sterility of the working field is maintained during surgery and a tight apical seal is achieved during the extraoral treatment, orthograde endodontic treatment should be delayed or avoided.

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.

Differential diagnosis between a granuloma and radicular cyst: effectiveness of magnetic resonance imaging

AIM

To investigate the diagnostic reliability and accuracy of magnetic resonance imaging (MRI) to differentiate periapical lesions of endodontic origin and to compare the results with histopathological information.

METHODOLOGY

The radiolucent periapical jaw lesions of 34 patients, which were surgically enucleated, were investigated by two radiologists using MRI, based on the same six criteria, to categorize the lesions as granulomas, radicular cysts or others. After apicoectomies, two oral pathologists (blinded to the radiologist's diagnoses) analysed all specimens by referring to seven specific parameters and diagnosed the specimens as granulomas, radicular cysts or other conditions. The inter-rater agreements between the radiologists and pathologists in terms of MRI and histological diagnoses, respectively, along with the discriminant power of the adopted criteria and the accuracy of the MRI assessments compared with the histopathological results, were calculated. Cohen's kappa test was adopted to examine inter-rater agreement between the two radiologists and two pathologists. Guttman's lambda coefficient (λ₆ ) was used to evaluate the internal consistency of the items used for the differential diagnosis by radiologists. The accuracy resulted from a receiver operator characteristic (ROC) analysis.

RESULTS

A strong inter-rater reliability was observed between the two radiologists (k-statistic = 0.86, P = 0.0001) and the two pathologists (k-statistic = 0.88, P = 0.0001). The internal consistency of the diagnostic items was 0.605 for cysts and 0.771 for granulomas. The accuracy (true positives plus true negatives) of the radiologists was greater than that of the pathologists based on analysis (area under the curve = 0.87 and 0.91, respectively).

CONCLUSIONS

The reliability and accuracy of MRI were high and comparable to histopathological reliability, highlighting the usefulness of this noninvasive technique as a pre-treatment diagnostic method for periapical endodontic lesions.

Dentists' perspectives on the choice of treatment of teeth with apical periodontitis

BACKGROUND AND AIM

Therapeutic decision in dentistry is a complex cognitive process for the practitioners because it involves taking into consideration several factors, including patients' preferences. The hypothesis of this study was that apicoectomy might be indicated more often than necessary and in order to confirm or invalidate it a survey was designed. We also aimed to explore whether the preferences were associated or not with dentist-related or practice-related characteristics.

METHODS

The survey included questions about treatment options in case of four scenarios, each one concerning an anterior and a posterior tooth with apical periodontitis, with or without previous endodontic treatment and also general questions, such as medical specialties, age and years of experience. The distribution of the questionnaires was done by email and direct distribution in the dental offices, in Cluj County, Romania.

RESULTS

After descriptive statistical analysis was performed, preferences rates were subjected to Chi-square test (including McNemar test for significance). Statistically significant differences were considered when p≤0.05.

CONCLUSIONS

The results indicate that dentists prefer nonsurgical endodontic treatment in case of a tooth with apical periodontitis. Apicoectomy was the second option treatment preferred by general dentists, oral and maxillo-facial surgeons, prosthodontists and endodontists.

In vitro evaluation of the apical seal of two different retrograde filling materials

To determine whether the selection of retrograde filling material or the choice of instruments in root tip resection influences the seal of the retrograde root filling. Seventy-two single-rooted teeth were used. Root resection was performed using a Lindemann bone cutter, a Lindemann bone cutter with A-shaped cutting design or a diamond-coated bur. Retro-cavities were prepared by piezo-tips and filled with Super-EBA or MTA. Teeth were made transparent and dye penetration was assessed. Teeth filled with MTA, irrespective of the resection instrument, showed no measurable dye penetration. All groups filled with Super-EBA showed an apical leakage. There were no significant differences between the three groups filled with Super-EBA (P = 0.09). The comparison of MTA versus Super-EBA showed significant superiority in apical seal in favour of MTA (P < 0.0001). To use MTA as a retrograde filling material showed superior results in terms of the tightness of the apical seal as compared to Super-EBA.

Scanning electron microscopy reveals severe external root resorption in the large periapical lesion

The present study was designed to investigate the relationships between clinicopathological findings and the resorptive conditions of root apices of teeth with periodontitis. The samples included 21 root apices with large periapical radiolucent lesions. The preoperative computed tomography (CT) and intraoperative findings were correlated with the presence, extension, and the progression pattern of periapical resorption using a scanning electron microscope. The subjects' age, gender, chief complaint, type of tooth, percussion test results, size of periapical lesion using CT, and intraoperative findings were recorded. All apicoectomies were performed under an operative microscope for endodontic microsurgery. A significant large size was observed in cystic lesions compared with granulomatous lesions. The cementum surface at the periphery of the lesion was covered with globular structures (2-3 μm in diameter). Cementum resorption started as small defect formations at the surface. As the defect formation progressed, a lamellar structure appeared at the resorption area, and the size of globular structures became smaller than that of globules at the surface. Further resorption produced typical lacuna formation, which was particularly observed in fracture cases. The most morphologically severe destructive pattern of dentin resorption was observed in large cystic lesions. This study is the first report to elucidate the relationships between three clinical types of undesirable periapical lesions: (1) undertreatment, (2) periapical fracture, (3) macro-level resorption, and the microstructure of external root resorption including from small defects at the cementum surface to a significant destructive pattern inside the dentin. Microsc. Res. Tech. 79:495-500, 2016. © 2016 Wiley Periodicals, Inc.

Surgical management of periapical lesion with dens in dente

The management of one case of dens in Dente (Dens invaginatus) in maxillary lateral incisor with history of trauma to maxillary central incisor with periradicular lesion is reported. The patient presented with pain and fracture of anterior tooth. Despite of complex anatomy and diagnosis of dens invaginatus, surgical root canal (Apicoectomy) was performed successfully. Further more essential clinical considerations and treatment options are suggested. Early diagnosis and management are important to avoid complications.