A novel surgical technique to resolve mucosal fenestration of a root apex: Apical tunnel surgery: A case report.

RATIONALE: Endodontic surgery, which includes apex resection, retro-fill and some regeneration procedures, is a traditional way to deal with apex fenestration. The endodontic surgery could bring large flap, curtate root length, non-healing mucosa and soft tissue deficiency in the apex area. Other treatment options might be considered according to different etiological factors. Mucogingival surgery provides some ideas in accumulation of soft and hard tissues, especially some unique methods such as "tunnel technique" bringing us a view of minimal invasive surgery approach. A novel surgery named "apical tunnel surgery" was reported here to resolve a root apex exposure with the tunnel-like technique. PATIENT CONCERNS: A young female complained about root exposure of upper right anterior tooth without history of trauma or orthodontic treatment. DIAGNOSIS: The intraoral examination revealed a buccal root apex exposure about 3mm in diameter of #12 (FDI teeth numbering system). The tooth was slightly dark with Class 1 mobility. The periodontal situation was good and the occlusion check revealed no traumatic bite on #12. The cone-beam computed tomography (CBCT) showed a bone fenestration from the buccally lower 1/2 root surface to the apex and bone absorption around the apex. It also revealed a bone contour deficiency in #12 area. INTERVENTIONS: Root canal treatment, root surface debridement, and soft tissue combined with hard tissue accumulation were carried out in one tunnel-like surgery. OUTCOMES: Examination of 12-month follow-up showed a healed and thickened mucosa in the buccally apical region and CBCT showed the continuous lamina dura occupied the buccal aspect of #12 root apex. LESSONS: This new apical tunnel surgery provided soft and hard tissue accumulation in one minimal invasive way in the apex exposure case caused by bone fenestration and thin mucosa.

Systematic review of surgical regenerative treatment for apicomarginal lesions in periapical surgery.

BACKGROUND: Apicomarginal lesions affect the root apex and root surface concurrently and reduce the success rate in periapical surgery. The purpose of this systematic review was to analyze the published literature on the surgical treatment of apicomarginal lesions in periapical surgery. MATERIAL AND METHODS: A systematic review was conducted on PRISMA statement. Three data bases (PubMed-Medline, Scopus, and Embase) were searched up to March 2023. The inclusion criteria for this systematic review encompass studies pertaining to apicomarginal lesions and their surgical treatment, both preclinical and clinical in nature (including randomized trials, prospective, and retrospective observational trials), without any language or time limitations. Exclusion criteria encompass studies with duplicated population data, no description of the surgical treatment or regenerative material. Different tools for the assessment of bias were applied for each study design Results: A total of 155 articles were searched and 10 were included. Studies on teeth with apicomarginal lesions undergoing periapical surgery showed a high success rate when regenerative techniques were used, resulting in reduced probing depth, increased bone formation on the root surface, increased root cementum formation, and reduced healing by junctional epithelium. Guided tissue regeneration, platelet-rich plasma or fibrin, and enamel matrix derivatives have emerged as alternative treatments offering favorable outcomes. CONCLUSIONS: The use of regenerative materials in periapical surgery could improve the prognosis of apicomarginal lesions. Future research in this field should aim to standardize classification and healing criteria to enhance comparability across studies and provide more conclusive evidence for optimal treatment approaches.

Effect of Recombinant Human Platelet-Derived Growth Factor on Healing of Chronic Periapical Tissue Pathosis Following Apical Surgery in a Canine Model: A Histomorphometric and Microcomputed Tomography Analysis.

This canine in vivo study assessed the effect of recombinant human platelet-derived growth factor (rhPDGF) on the healing of periapical tissues following apical surgery. From a total of 96 premolar teeth, 64 teeth from six beagle dogs (2 years old) were classified as experimental and were randomly assigned to four experimental groups (16 teeth per group). After having the pulp extirpated, leaving teeth open to the oral cavity for 1 week, and sealing with an immediate restorative material for 8 weeks, nonsurgical endodontic treatment was performed. A split-mouth design was used, and intra-animal randomization of treatment sides was applied to the groups as follows: apical curettage + 1.5-mm root-end resection (Group 1); apicoectomy + mineral trioxide aggregate (MTA) root-end filling (Group 2); apicoectomy + MTA root-end filling + rhPDGF (Group 3); and apical curettage + rhPDGF (Group 4). The animals were sacrificed 24 months after apical surgery, and histologic and µCT analyses were performed for bone volume loss (BVL). Group 1 showed partial resolution of the periapical lesions without signs of tissue regeneration (BVL: 49.09 ± 10.97 mm3). Group 2 had minimal bone regeneration and showed cementum reformation in 9 teeth, with no direct attachment to the MTA (BVL: 35.34 ± 10.97 mm3). Group 3 showed regeneration of all damaged apical tissues without direct contact between the cementum and MTA (BLV: 4.51 ± 1.55 mm3). Group 4 showed regeneration of PDL, bone, and cementum and attachment of functional cementum fibers (BVL: 2.82 ± 2.3 mm3). The difference in BVL was statistically significant only for Groups 1 and 2 (P < .05). rhPDGF may help regenerate apical tissue structures following apical surgery.

Traumatismo em dente com rizogênese incompleta: caso clínico / Traumatism in tooth with incomplete rizogenesis: clinical case

O traumatismo dentário acontece de maneira frequente, tendo maior prevalência em incisivos centrais, podendo ocorrer de várias formas, acometendo o tecido duro e o tecido de sustentação do dente. A severidade do trauma pode ocasionar um processo degenerativo ou uma lesão irreversível até a mortificação da polpa, por isso deve-se observar o estágio de desenvolvimento do dente para correta terapêutica diante de uma rizogênese completa ou incompleta. A necrose pulpar em um dente com ápice incompleto paralisa o seu processo de desenvolvimento o que torna necessário a realização da apicificação. O objetivo desse presente trabalho é relatar um caso clínico de traumatismo em um dente com rizogênese incompleta e a conduta terapêutica instituída para promover a apicificação do mesmo. Entretanto, Durante o tratamento foi um grande desafio promover o fechamento do ápice que fora paralisado após o trauma. Portanto, foi preciso realizar várias sessões de medicação intracanal com hidróxido de cálcio que é o material mais indicado para induzir a formação de barreira calcificada para fechamento completo do ápice(AU)

The dental trauma occurs frequently, having a higher prevalence in central incisors, and can occur in several ways, affecting the hard tissue and the tooth support tissue. The severity of the trauma can cause a degenerative process or an irreversible lesion until the mortification of the pulp, so the stage of development of the tooth must be observed for correct therapy in the presence of complete or incomplete rhizogenesis. Pulp necrosis in a tooth with an incomplete apex paralyzes its development process, which makes it necessary to perform the inoculation. The objective of this present work is to report a clinical case of trauma in a tooth with incomplete rhizogenesis and the therapeutic conduct instituted to promote the apicification of the same. However, during the treatment it was a great challenge to promote the closure of the apex that had been paralyzed after the trauma. Therefore, it was necessary to perform several intracanal medication sessions with calcium hydroxide, which is the most suitable material to induce the formation of a calcified barrier for complete closure of the apex(AU)

Radiographic Assessment of Bone Healing Using Cone-beam Computed Tomographic Scans 1 and 5 Years after Apical Surgery.

INTRODUCTION: The objective of this long-term study was to evaluate radiographic healing in cone-beam computed tomographic (CBCT) scans taken 1 and 5 years after apical surgery. METHODS: In the context of a prospective clinical study, postsurgical CBCT scans were taken 1 and 5 years after apical surgery. Three calibrated observers independently assessed buccolingual CBCT images oriented along the longitudinal axis of the treated roots. Radiographic periapical healing was categorized as "fully, partially, or not healed" for each of the following study parameters: the resection plane, the cortical plate, the apical area, and the overall bone healing. The analysis included the interobserver agreement (Fleiss kappa values), the comparison of 5- and 1-year ratings, and the changes of healing categories from 1-5 years (McNemar-Bowker tests). Data were analyzed statistically for the detection of significant differences. RESULTS: CBCT images of 41 teeth (in 41 patients) with 47 treated roots were evaluated. At 5 years, all studied parameters had higher rates of fully healed cases compared with the rate at 1 year. The resection plane and apical area parameters each were judged in 72.3% as fully healed at 5 years, whereas the cortical plate and overall bone healing parameters showed clearly lower fully healed rates (42.6% and 38.3%, respectively). Fully healed cases at 1 year remained so at 5 years in 87.5%-100% depending on the study parameter. CONCLUSIONS: This 5-year CBCT follow-up study of apical surgery showed a marked improvement of radiographic healing from 1-5 years but to a varying degree regarding the different study parameters. Although new hard tissue formation at the resection plane and within the former apical defect was advanced in most cases at 5 years, the reestablishment of the cortical bone plate clearly lagged behind.

The evaluation of apicectomy without retrograde filling in terms of lesion size localization and approximation to the anatomic structures.

BACKGROUND: The purpose of this study was to evaluate of the patients who underwent apical resection. Besides assess the classification of resection side, localization, lesion size, approximation of anatomic structures and the purpose of the apical surgery retrospectively. MATERIAL AND METHODS: In this stutdy 782 patients and 1191 apical resection applied tooth evaluated. 504 of the patients were famale and 278 were male. Patients age was between 13 and 76 years old and operated between January 2016 and January 2017. The study includes incisor, canine and premolar teeth which had the apical resection as the first time. Operation side evaluated from orthopantomograph and periapical radiographs. RESULTS: There were 1191 teeth operated and 966 of them in maxilla and 225 of them in mandible. The number of the incisor teeth were 871, 177 were canine, 129 were premolar and one of them was molar. The total amount of 468 patients had operated by just 1 tooth, 454 of the operated teeth had cyst on the operation side. Premolar and molar side 21 of the 93 lesion had approximation with maxillar sinus. On the other hand in maxilla 39 of 569 lesion had approximation with nasal cavity. In mandibula 1 of the 15 lesion, which involved mandibular premolar teeth, had approximation with mental foramen. CONCLUSIONS: Apical resection operation mostly done for one tooth, and the lesion size was less than 10 milimeters. Furthermore apical resection mostly done for incisors cause of odontogenic cyst.

A 10-year Follow-up Study of 119 Teeth Treated with Apical Surgery and Root-end Filling with Mineral Trioxide Aggregate.

INTRODUCTION: The objective of this clinical study was to assess the long-term outcome (clinical signs/symptoms and radiographic healing) of teeth treated with apical surgery and mineral trioxide aggregate (MTA) for root-end filling. METHODS: One hundred ninety-five patients were recalled 1, 5, and 10 years after apical surgery for clinical and radiographic examinations. Three calibrated observers evaluated the periapical radiographs independently. The evolution of the cases over time was analyzed. Healing classification of teeth was divided into "healed" versus "not healed" teeth using well-established clinical and radiographic healing criteria. The potential influence of sex, age, type of treated tooth, type of MTA, and first-time versus repeat surgery on healing outcome was statistically analyzed. RESULTS: The inception cohort included 195 teeth. The dropout rate after 10 years amounted to 39% (n = 76). Of the 119 teeth available for the 10-year analysis, 97 teeth were classified as healed (81.5%). No significant differences were found with regard to the rate of healed cases for the subcategories of the parameters of age, sex, type of MTA, and first-time or repeat surgery. Concerning the type of treated tooth, the rate of healed maxillary molars (95.2%) differed significantly (P = .035) from the rate of healed maxillary premolars (66.7%). The predictive value of the cases classified as healed at 1 year and remaining so over the 10-year observation period was 86.8%. CONCLUSIONS: This 10-year follow-up study of teeth treated with apical surgery and MTA as root-end filling material showed an acceptable rate of healed cases. Many of the lost teeth had been extracted because of longitudinal root fractures during the observation period.

Outcome assessment of apical surgery: A study of 234 teeth.

BACKGROUND/PURPOSE: Apical surgery is an option for management of endodontically-treated tooth with persistent periapical lesions or symptom and sign. The objective of this study was to investigate the correlation between the demography, preoperative, postoperative factors and healed rate of apical surgery. METHODS: Subjects were retrospectively collected from patients who received apical surgery/apicoectomy at the Endodontic Department, National Taiwan University Hospital from January 2013 to June 2015. The standard apical surgery procedures were performed. The demography, preoperative clinical and radiographic examination data as well as postoperative variables were collected. The outcome assessment was carried out after surgery. Statistical analysis was performed by chi square test to evaluate the potential outcome predictors. RESULTS: Total 187 patients and 234 teeth receiving apical surgery were included. 53 male and 134 female patients were collected. The age was ranged between 17 and 89 years old and the mean age was 43.64 years old. Better healed rate with significant differences were observed in female patient (p < 0.05), age ≤60 years old (p < 0.01), preoperative root canal filling material >2 mm short of apex (p < 0.01), lesion size from ≤2 mm to ≤12 mm (p < 0.05) and follow-up period â‰§12 months (p < 0.01) groups. CONCLUSION: Gender, age, preoperative root canal filling material extent, lesion size and follow-up period may affect the outcome of apical surgery. Tooth type, post, prosthesis, and lesion area showed no marked effect on apical healing. These results provide more detailed information for the clinical practitioners to make treatment plans and are important for clinical endodontic practices.

Management and Histobacteriological Findings of Mucosal Fenestration: A Report of 2 Cases.

This article describes 2 unusual cases of mucosal fenestration associated with necrotic infected teeth, resulting in exposure of the root apex to the oral cavity. Both cases consisted of maxillary incisors with pulp necrosis and radiographic/tomographic evidence of apical periodontitis. Clinically, the root apex was exposed to the oral cavity through a fenestration in both bone and mucosa and covered with bacterial plaque and calculus. These teeth were treated by a combination of nonsurgical and surgical endodontic treatment. During surgery, the root apices were resected to within the alveolus and the fenestrated area covered by the flap. Specimens consisting of the root apex and surrounding soft tissues were subjected to histopathological and histobacteriological analyses. Histobacteriological analysis revealed extensive resorptive defects on the root apices filled with thick bacterial biofilm, irregular detachment of the cementum layers with consequent infection of the underlying spaces, and heavy infection in the apical foramina. The soft tissue specimens exhibited no or minimal inflammation. The 2 cases showed satisfactory postsurgical healing of the hard and soft tissues. Both cases of mucosal fenestration showed root apices covered with dense bacterial biofilms and associated with a bone crypt with no significant inflammatory tissue therein. The 2 cases were successfully treated by conservative approaches involving a combination of nonsurgical and surgical endodontic treatment with root-end resection.

Periapical Microsurgery: Do Root Canal-retreated Teeth Have More Dentinal Defects?

INTRODUCTION: This microsurgical clinical study evaluated if teeth that have undergone endodontic retreatment are associated with more dentinal defects than primary root canal-treated teeth. METHODS: One hundred fifty-five patients who underwent periapical microsurgery treatment in a private practice setting were evaluated. The root ends were resected, and the roots were inspected for the presence of dentinal defects through the surgical operating microscope with the help of a 0.8-mm-diameter light-emitting diode probe light and methylene blue dye. The root canal treatment history (primary vs retreatment) of the teeth was documented and related to the presence or absence of dentinal defects. Bivariate analysis was performed using the chi-square test, and a multivariate analysis was performed using logistic regression to evaluate possible confounding effects of patient age, sex, and tooth location on the association between treatment and the presence of dentinal defects. RESULTS: Of the 155 treated teeth, 33 were excluded (3 fractured and 30 missing treatment history). Of the remaining 122 included teeth, 73 (59.8%) had undergone primary root canal treatment and 49 (40.2%) retreatment. Sixteen teeth (22.5%) of the primary root canal group versus 33 (64.7%) of the retreatment group had dentinal defects. The proportion of retreated teeth with dentinal defects compared with primary treatment was statistically significant (P < .001) with a higher proportion of retreated teeth having dentinal defects. In the multivariate analysis, only the type of treatment was statistically significant (P < .001). CONCLUSIONS: This clinical study showed that root canal-retreated teeth are associated with more dentinal defects than primary root canal-treated teeth.

Effects of Different Glide Path Files on Apical Debris Extrusion in Curved Root Canals.

INTRODUCTION: Creating a glide path before root canal preparation with nickel-titanium rotary files is essential to prevent the file fracture and to maintain the original root canal configuration. Both rotary glide path files and manual K-files are used to create a glide path. The aim of this study was to compare the amount of apically extruded debris after using different glide path files before preparing curved root canals with the WaveOne Gold single-file reciprocating system (Dentsply Maillefer, Ballaigues, Switzerland). METHODS: Sixty extracted mandibular first molar teeth with curved mesial roots were selected for this study. The mesial roots of the teeth were removed from the cementoenamel junction. Cone-beam computed tomographic imaging was used to evaluate the curvature of the mesial root canals. Specimens were randomly divided into 6 experimental groups according to the root canal preparation (n = 10): group G-File, a glide path with G-Files (Micro-Mega, Besancon, France) + WaveOne Gold preparation; group One G, a glide path with One G (Micro-Mega, Besancon, France) + WaveOne Gold preparation; group ProGlider, a glide path with ProGlider (Dentsply Maillefer) + WaveOne Gold preparation; group PathFile, a glide path with PathFiles (Dentsply Maillefer) + WaveOne Gold; group K-files, a glide path with a K-file + WaveOne Gold preparation; and group without a glide path, WaveOne Gold preparation without a glide path file. Roots were attached to preweighed Eppendorf tubes. All instruments were used according to the manufacturers' instructions. During root canal preparation, a total of 8 mL distilled water was used for each specimen. Apically extruded debris was collected in Eppendorf tubes. After the completion of root canal preparation, Eppendorf tubes were removed from the specimens and stored in an incubator at 68°C for 5 days. Eppendorf tubes were weighed after evaporation to calculate the amount of extruded debris. The data were statistically analyzed with 1-way analysis of variance and post hoc Tukey honest significant difference tests (P = .05). RESULTS: A statistically significant difference was observed between the One G and K-File groups. The One G group was associated with significantly less debris extrusion than the K-file group. There was no statistically significant difference between K-files and ProGlider, G-Files, PathFiles, and WaveOne Gold without a glide path, and also there was no statistically significant difference between One G and ProGlider, G-Files, PathFiles, and WaveOne Gold without a glide path. All experimental groups caused apical debris extrusion. CONCLUSIONS: Under the conditions of this in vitro study, all rotary path file systems were associated with similar apical debris extrusion before preparing root canals with the WaveOne Gold single-file reciprocating system. K-files caused more apically extruded debris than the One G files.

Evaluation of apically extruded debris using continuous rotation, reciprocation, or adaptive motion

Abstract The aim of this study was to compare the amount of apically extruded debris during root canal instrumentation using ProTaper Next (PTN), Twisted File (TF) Adaptive, and Reciproc instruments. Forty-five extracted human maxillary canines were selected and randomly assigned into 3 groups. The root canals were prepared using PTN instruments with continuous rotation (n=15), TF Adaptive instruments with adaptive motion (n=15), Reciproc instruments with reciprocating motion (n=15). During the preparations, canals were irrigated using distilled water and material extruded apically was collected in pre-weighed Eppendorf tubes. After a 5-day drying period in an incubator, the tubes were weighed and the dry weight of the extruded debris was calculated. Data distributions were assessed via the Shapiro-Wilk test, and groups were compared via the Kruskal-Wallis test. The greatest amount of debris extruded by TF Adaptive and the least by PTN, but the difference was insignificant between groups (p=0.259). All instrumentation systems were associated with debris extrusion.

Resumo O objetivo deste estudo foi comparar a quantidade de detritos apicalmente extruídos durante a instrumentação do canal radicular usando os instrumentos ProTaper Next (PTN), Twisted File (TF) Adaptative e Reciproc. Quarenta e cinco caninos superiores humanos extraídos foram selecionados e distribuídos aleatoriamente em 3 grupos. Os canais radiculares foram preparados utilizando instrumentos PTN com rotação contínua (n = 15), instrumentos TF Adaptative com movimento adaptativo (n = 15), instrumentos Reciproc com movimento oscilatório (n = 15). Durante os preparos, os canais foram irrigados com água destilada e o material extruído foi coletado apicalmente em tubos Eppendorf pré-pesados. Após um período de secagem de 5 dias numa incubadora, os tubos foram pesados e o peso seco dos resíduos extruídos foi calculado. A distribuição dos dados foi avaliada pelo teste de Shapiro-Wilk e os grupos foram comparados pelo teste de Kruskal-Wallis. A maior quantidade de detritos extruídos foi proporcionada pelo TF Adaptive e a menor pelo PTN, mas a diferença não foi estatisticamente significante entre os grupos (p=0,259). Todos os sistemas de instrumentação promoveram extrusão de detritos apicalmente.

Apically Extruded Debris during Root Canal Instrumentation with Reciproc Blue, HyFlex EDM, and XP-endo Shaper Nickel-titanium Files.

INTRODUCTION: The purpose of this study was to investigate the amount of apically extruded debris by Reciproc Blue (REC Blue; VDW, Munich, Germany), HyFlex EDM (HEDM; Coltene/Whaledent, Altstätten, Switzerland), and XP-endo Shaper (XPS; FKG Dentaire SA, La Chaux-de-Fonds, Switzerland) files during root canal preparation at body temperature. METHODS: Sixty extracted single-rooted mandibular premolar human teeth were randomly assigned to 3 groups (n = 20). The canals were instrumented using 1 of the following instruments: REC Blue, HEDM, or XPS. Apically extruded debris during instrumentation was collected into preweighed Eppendorf tubes. All the procedures were performed at 35°C. The amount of extruded debris was calculated by subtracting the weight value of the tooth-free apparatus from the postpreparation weight value. The data were analyzed using the Kruskal-Wallis test at a 5% significance level. RESULTS: All the instruments tested caused extrusion of some debris from the apical foramen. XPS extruded significantly less debris from the apex than REC Blue (P < .05). The difference among the HEDM group and the other groups was not significant (P > .05). CONCLUSIONS: Within the limitations of this in vitro study, the amount of apically extruded debris registered for the different files tested was REC Blue > HEDM > XPS, with a statistical difference only between XPS and REC Blue.

Prevalence of vertical root fractures in teeth planned for apical surgery. A retrospective cohort study.

AIM: To evaluate retrospectively the prevalence of vertical root fractures (VRFs) in a cohort of patients during apical surgery and the factors possibly associated with VRF. METHODOLOGY: The sample consisted of 944 root filled teeth belonging to 768 patients (49.3% males and 50.7% females; mean age 43.5 ± 11.2 years, range 22-68 years), consecutively referred for endodontic surgery over a six-year period. All patients underwent a clinical assessment of their signs and symptoms. Periapical radiographs of teeth that were candidates for endodontic surgery were taken. Sixty-eight teeth with VRF were identified. Vertical root fractures were identified in pre-surgical screenings in 32 cases (47.1%), and these did not undergo surgery. Another 36 cases of VRF were noted during the intervention for root-end resection. The influence of posts, post type, tooth type, periodontal probing defects, spontaneous pain, sinus tract and follow-up duration was assessed using a logistic regression analysis. RESULTS: Vertical root fractures occurred significantly more frequently (P < 0.001) when a post was present (61 VRF out of 377 teeth with post, prevalence 16.2%) than in teeth without a post (1.2%). Threaded posts and cast posts were significantly more involved in VRF than fibre, silica or carbide posts (P < 0.001). Most fractures (80.9%) occurred 1-5 years after root canal treatment. Sinus tracts, probing defects and spontaneous pain were significantly more associated with VRF cases than with nonfractured teeth. CONCLUSIONS: In the present group of teeth, the major risk for VRF was represented by posts retained by actively engaging the canal via mechanical design (thread) or by frictional fit (cast).

Targeted Endodontic Microsurgery: A Novel Approach to Anatomically Challenging Scenarios Using 3-dimensional-printed Guides and Trephine Burs-A Report of 3 Cases.

Endodontic microsurgery (EMS) techniques have increased success rates over traditional approaches. Despite surgical advances, anatomically challenging scenarios can preclude EMS in certain cases. The aim of this article was to introduce targeted EMS, which uses 3-dimensional-printed surgical guides (3DSGs) and trephine burs to achieve single-step osteotomy, root-end resection, and biopsy in complex cases. In each of 3 cases, a 3DSG with a trephine port was printed using computer-aided design/computer-aided manufacturing implant planning software. The osteotomy site, angulation, and depth of preparation were defined preoperatively to avoid sensitive anatomic structures. The 3DSG was inserted at the target site to achieve precise osteotomy and root-end resection during surgery. A hollow trephine rotated within the 3DSG port produced single-step osteotomy, root-end resection, and biopsy. Root-end preparation and fill were accomplished, and tissues were sutured in place. Targeted EMS potentiated successful surgical treatment in 3 anatomically challenging scenarios: (1) a palatal approach to the palatal root of a maxillary second molar, (2) a facial approach to a fused distofacial-palatal root of a maxillary first molar, and (3) a mandibular second premolar in close proximity to the mental foramen. Trephine burs guided by 3DSGs produce efficient targeted osteotomies with a predictable site, angulation, and depth of preparation. Apical surgery in challenging anatomic cases such as the palatal root of the maxillary second molar, fused molar roots, and root ends in approximation to the mental nerve are possible with targeted EMS.

Marginal Gaps between 2 Calcium Silicate and Glass Ionomer Cements and Apical Root Dentin.

INTRODUCTION: The outcome of periapical surgery has been directly improved with the introduction of novel material formulations. The aim of the study was to compare the retrograde obturation quality of the following materials: calcium silicate (Biodentine; Septodont, Saint-Maur-des-Fosses, France), mineral trioxide aggregate (MTA+; Cerkamed Company, Stalowa Wola, Poland), and glass ionomer cement (Fuji IX; GC Corporation, Tokyo, Japan). METHODS: Materials' wettability was calculated concerning the contact angles of the cements measured using a glycerol drop. Cements' porosity was determined using mercury intrusion porosimetry and micro-computed tomographic (µCT) imaging. Extracted upper human incisors were retrofilled, and µCT analysis was applied to calculate the volume of the gap between the retrograde filling material and root canal dentin. Experiments were performed before and after soaking the materials in simulated body fluid (SBF). RESULTS: No statistically significant differences were found among the contact angles of the studied materials after being soaked in SBF. The material with the lowest nanoporosity (Fuji IX: 2.99% and 4.17% before and after SBF, respectively) showed the highest values of microporosity (4.2% and 3.1% before and after SBF, respectively). Biodentine had the lowest value of microporosity (1.2% and 0.8% before and after SBF, respectively) and the lowest value of microgap to the root canal wall ([10 ± 30] × 10-3 mm3). CONCLUSIONS: Biodentine and MTA possess certain advantages over Fuji IX for hermetic obturation of retrograde root canals. Biodentine shows a tendency toward the lowest marginal gap at the cement-to-dentin interface.

Computer-aided Design/Computer-aided Manufacturing-guided Endodontic Surgery: Guided Osteotomy and Apex Localization in a Mandibular Molar with a Thick Buccal Bone Plate.

A mandibular molar with a thick buccal bone plate is a challenging problem in endodontic surgery despite the increase in the success rate of endodontic surgery nowadays. This report describes the application of a surgical template to guide osteotomy and facilitate apex localization in a mandibular molar with a thick buccal bone plate. A 57-year-old woman visited the authors' clinic for pain in tooth 19 and was diagnosed with symptomatic apical periodontitis in this previously treated tooth. Nonsurgical retreatment was performed; however, 2 years later, the patient reported pain in the same tooth. A periapical lesion was confirmed using cone-beam computed tomographic (CBCT) imaging, and endodontic surgery on the mesial root of tooth 19 was planned. After CBCT imaging and cast scan data were transferred to implant surgical planning software, the data were superimposed. In the superimposed model, an anchor pin was designed to target the mesial root apex of tooth 19. The surgical template was then printed using a 3-dimensional printer. Endodontic microsurgery included application of this printed surgical template. A computer-aided design/computer-aided manufacturing (CAD/CAM)-guided surgical template minimized the extent of osteotomy and enabled precise targeting of the apex in this case. There were no postoperative complications. A CAD/CAM-guided surgical template is useful in endodontic surgery for complicated cases.

An Innovative Regenerative Endodontic Procedure Using Leukocyte and Platelet-rich Fibrin Associated with Apical Surgery: A Case Report.

Regenerative endodontic procedures (REPs) associated with apical surgery could represent an alternative treatment strategy for patients whose teeth present incomplete root formation and extensive apical lesions. Leukocyte platelet-rich fibrin (L-PRF) has potential benefits in REPs; it could promote apical root formation and optimal bone healing. The aim of this case report was to describe innovative regenerative endodontic therapy using L-PRF in the root canal and an extensive apical lesion in an immature tooth with dens invaginatus and asymptomatic apical periodontitis. A healthy 20-year-old woman was referred to the dental clinic of the Universidad de Los Andes, Santiago, Chile, for endodontic treatment in tooth # 22 with incomplete root development and an extensive apical lesion. The diagnosis was asymptomatic apical periodontitis associated with dens invaginatus type II. The patient was treated with an innovative approach using L-PRF in REPs associated with apical surgery. Follow-ups were performed at 6 months and 1 year later. They included periapical radiographs, cone-beam computed tomographic imaging, sensitivity, and vitality tests. The clinical evaluations performed at 6 months and 1 year revealed an absence of symptoms. The radiographic evaluations showed that the apical lesion was resolved. The cone-beam images indicated that the root length increased and the walls had thickened. The sensitivity tests were positive, and the laser Doppler flowmetry showed positive blood flow after 1 year. The success of the results in this case report indicate that L-PRF can be used as a complement in apical surgery and REPs and could provide an innovative alternative treatment strategy for complex clinical cases like these.

[Effects of different techniques on removal of vapor lock in the apical region of curved canals: a cone-beam computed tomography study].

OBJECTIVE: To compare the effect of four different techniques on removal of vapor lock in the apical region of curved root canals. METHODS: Forty simulated resin root canals with 45° curvature were prepared using WaveOne Primary, then the apical foramen were sealed with soft wax. The teeth were divided randomly into 4 groups thereafter (n=10). Contract solution was injected into the canals using a 30 G side-vented needle and scanned with cone-beam CT (CBCT) to identify the volume of the vapor lock. Four different techniques including photon-induced photoacoustic streaming (PIPS) laser-activated irrigation, gutta-percha cone technique, ultrasonic irrigation, and sonic irrigation were used to remove the vapor locks in the root canals. The residual volume of the vapor lock was identified again using CBCT scanning data. Accordingly, the reduction rates of the vapor lock were calculated. Furthermore, the initial and residual vapor lock length was calculated. The data were analyzed by using the One-way ANOVA analysis and Kruskal-Wallis H test at a significance level of P<0.05. RESULTS: There was no significant difference in the initial vapor lock volume (P>0.05). Residual volume of the vapor lock for PIPS laser-activated irrigation was 0 mm(3), and that for gutta-percha cone technique was (0.02±0.07) mm3, significantly lower than those of ultrasonic and sonic irrigation, the values being (0.20±0.09) mm(3) and (0.23±0.06) mm(3) (P<0.001), respectively. The reduction rates of the vapor lock of PIPS laser-activated irrigation and gutta-percha cone technique were 100.00% (100.00%, 100.00%) and 100.00% (77.66%, 100.00%), respectively, significantly higher than those of ultrasonic irrigation [70.37% (56.41%, 91.43%)] and sonic irrigation [63.54% (51.47%, 74.00%), P<0.001]. The length of the residual vapor lock for PIPS laser-activated irrigation was 0 mm, and that for gutta-percha cone technique was (0.15±0.47) mm, significantly lower than those of ultrasonic and sonic irrigation, values being (2.21±0.09) mm and (2.34±0.08) mm (P<0.001), respectively. The length of the residual vapor locks in the ultrasonic and sonic group remained approximately the same as the distance between the working tip and the apical foramen. CONCLUSION: PIPS laser activated irrigation and gutta-percha cone technique could remove the vapor lock from the apical region of curved canals effectively.

Potential reformatting errors in cone-beam computed tomography for dentoalveolar surgery: a cautionary tale.

We describe the removal of a lower second molar tooth in which preoperative cone-beam computed tomography (CBCT) showed that the inferior alveolar nerve (IAN) was encased in the distal apex of the root of the tooth. During operation the nerve was found to be entirely separate from the apex of the root and not involved. With the wider use of CBCT in the treatment planning of dentoalveolar surgery, this case represents a cautionary tale to the clinician on reliance on clinical imaging and software in guiding the decision making process.