Delayed post-extraction implants placed using a modified Summers technique: Preliminary results of a single cohort study.

The aim of this retrospective case series was to evaluate the clinical and radiographic outcomes of the patients that underwent implant surgery with a modification of the sinus lift summers protocol. Forty healthy patients in need for oral rehabilitation with dental implants were included in this study. Inclusion criterion was the need for extraction of one compromised tooth due to persistent abscess/ periodontitis/cyst in the atrophic posterior maxilla region. The treatment consisted of two stage surgery for all patients. In the first stage, after tooth extraction, the sockets were preserved with allogenic bone graft and equine collagen membrane. After 4-5 months, 40 implants with a sandblasted surface, were inserted with osseodensification technique and a modification of the Summers sinus lift protocol for fracturing the sinus floor. The implant survival rate was the primary outcome. Intra- and postoperative complications were additional criteria for success. The mean follow-up from implant surgery was 28.0±7.3 (standard deviation) months (range 17.8-43.4 months). One implant was lost before the delivery of the prosthesis. The overall implant survival rate was 97.5%. The overall mean peri-implant marginal bone level change after 6 and 12 months of function was, respectively, 0.26±0.24 mm (95% CI: 0.19, 0.34 mm) and 0.71±0.36 mm (95% CI: 0.60, 0.82 mm). Marginal bone loss was statistically significant at both time frames respect to implant placement, and also the difference between 6 and 12 months was significant (p<0.001 in both cases). No biological nor mechanical complications were recorded throughout the observation period. As a conclusion, the technique presented in this cohort study can be an effective and safe alternative to standard maxillary sinus floor augmentation procedures and immediate implant insertion protocol, especially in cases of periodontitis and infected sites, which can represent a high risk for implant failure in patients with atrophic posterior maxilla.

Evaluation of mental foramen and inferior alveolar nerve canal and its relationship to adjacent anatomical landmarks using cone-beam computer tomography.

The objective of the research was to evaluate the location, size, variability, and morphologic features of mental foramen (MF) and the inferior alveolar nerve canal (IAN) on cone-beam CT. We evaluated the morphologic findings of mental foramen (MF) and inferior alveolar nerve (IAN) canal of 88 mandibular hemiarches of 65 Caucasian subjects (35 males, 30 females; age range 25-75 years) using cone beam CT. The most common horizontal position of MF was type 3 (53.4%), followed by type 4 (39.8%), type 1 (2.3%), type 2 (2.3%), and type 5 (2.3%). Regarding the vertical position, in 71.6% of cases (63/88) we found type 3 position, followed by type 2 (22.7%) and type 1 (5.7%). MF presented as oval in 51.1% and round in 42%, with double oval and triple foramens having been observed in 5.7% and 1.1% respectively. In 36.9% of cases, we found an anterior loop of the IAN. The mean depth of MF was 6.12±1.65mm; width and height were 3.7±0.83mm and 3.14±0.78mm. Width and height of the IAN distal to MF were 2.27±0.53mm and 2.74±0.51mm, while those of the incisive nerve canal mesial to MF were 1.37±0.44mm and 1.54±0.58mm, respectively. An increase in the width of MF was correlated to oval shape (r=0.45; P < 0.01), and there was a low but significant correlation (r=0.23; P < 0.05) between the round shape of MF and the size of the IAN. MF shape appears to be correlated to MF width and size of the IAN. The individual anatomical variability of this structure is a factor that must be considered when dealing with mandibular surgery.

A 3D evaluation of the upper airways and sagittal craniofacial pattern: are these two parameters associated?

Numerous studies have been published aiming to investigate the relationship between sagittal craniofacial pattern and the dimensions of upper airway, but with controversial results. The aim of the study is to verify if an association exists between a specific sagittal cranio-facial pattern and smaller dimensions of upper airway, leading so to a possible risk indicator for OSAS development. Ninety-nine cone-beam computed tomographies (CBCT) were selected from adult patients (48 males, 51 females, age range 18- 65 years). Patients were divided into 3 groups, with 33 patients each, according to their skeletal class (I: 13; III: ANB<1). The CBCT data were imported into Simplant O&O software as Dicom files. Borders for the oropharynx and for the hypopharynx of which the volumes were calculated, and the total length (L) were defined. Finally, the average cross-sectional area (a-CSA) was defined as the ratio between total volume and total length for each patient. All data were statistically analyzed using GraphPad Software. A significant difference was found between groups for oropharynx, hypopharynx, and total volume, with Class II having smaller airway dimensions. In a gender-based comparison, there was a statistically significant difference between female and male patients of the same group, and between the same gender in different groups. Regarding the total length and the a-CSA, there was a statistically significant difference between the groups. These results indicate that class II and female patients have smaller dimensions of upper airway leading to a possible risk indicator for OSAS development.

Effect of concentrated growth factors on quality of life of patients undergoing implant therapy: a cohort study.

Pain, bad taste, and impaired daily activity after implant therapy are common sequelae. Concentrated growth factors (CGF) are a platelet concentrate with a favourable effect on wound healing, but there is still no evidence regarding its potential benefits for reducing postoperative pain and symptoms. Therefore, aim of this prospective comparative study was to determine the effect of CGF on quality of life (QoL) of patients after implant therapy. Fifty-two consecutive patients with one missing mandibular molar were included in the study and alternatively assigned to two groups. Control group received standard implant treatment, and test group received CGF associated with implants. Standard periapical radiographs were taken before and after procedure. Post-operative care consisted of 0.2% chlorhexidine digluconate solution twice daily for 10 days. A QoL questionnaire (OHIP-14) for bad taste, pain and limitation in daily activities was filled and returned one week post-operatively. Daily pain was also assessed through Visual Analogue Scale (VAS) on a 1-100 scale. Parametric test (chi-square) was performed to compare the results of the questionnaire between the two groups using STATA statistical software. All patients correctly filled and returned the questionnaire. Significantly higher proportions of patients of test group reported no bad taste, pain, and limited activity, (24/26, 13/26, and 25/26, respectively) respect to control. Postoperative pain with VAS score was significantly lower in the test group on day 1, 2, and 3 as compared to control. CGF positively influenced QoL when associated with implant rehabilitation of mandibular molars, minimizing post-operative discomfort.

Cutaneous and oral comorbidities in patients with geographic tongue: a multicenter multidisciplinary cross-sectional observational study.

Geographic tongue (GT) represents a localized type of psoriasis inversa and its burden of dermatological and oral comorbidities frequently conditions its severity and diagnosis. Currently, no epidemiological studies have evaluated GT muco-cutaneous comorbidities. We aimed to study oral and dermatological comorbidities in a large sample of GT patients. In this multicenter, cross-sectional study, involving 4 primary referral centers in Italy, we evaluated adult GT patients, who were assessed by board certified dermatologists and dentists for 5 months and collected demographics and medical history. GT was evaluated using Hume's classification together with Geographic tongue severity index (GTASI) to score its severity. The prevalence of oral and dermatological comorbidities was recorded. In the sample we enrolled 137 GT patients (M/F= 5:1) with a mean age of 48,2 ± 14,7 yoa and 33.6% had GT family history. The clinical evaluation found 96 (70.1%) GT type I, 7 (5.1%) type II, 13 (9.5%) type IIIa, 19 (13.9%) type IIIb, 2 (1.5%) type IV, following Hume's classification. The mean GTASI score was 23,7 ± 14,2 and the vast majority displayed a severe form of GT. Eighty-nine patients had oral comorbidities (burning mouth syndrome, caries, parulid and lichen planus) and 80 had dermatological concurrent conditions (plaque psoriasis, inverse psoriasis and atopic dermatitis). In GT patients, both dermatological and dental evaluation should be mandatory to identify previously undiagnosed mucocutaneous comorbidities.

Geographic tongue clinical response in moderate-to-severe psoriatic patients undergoing secukinumab: a real-life, multicenter retrospective observational study.

Geographic tongue (GT), a form of inverse psoriasis, is frequently linked to plaque psoriasis. The objective of the study is to evaluate IL-17 blocker (secukinumab) effect on GT severity. This reallife, multicenter, retrospective observational pilot study evaluated patients with plaque psoriasis and concomitant GT that started in label treatment with secukinumab. Patients were evaluated twice (T0=baseline and T1=after 16 weeks) by a dentist and a dermatologist collecting data on cutaneous Psoriasis Area Severity Index (PASI) and oral statuses using Hume's classification of the Geographic Tongue Severity Index (GTASI). Twenty-nine psoriatic patients with GT treated with secukinumab were enrolled for the study. Seventeen patients display type I GT, 6 type II and 6 type III with an overall GTASI of 25.52±9.57 at the baseline (T0). No correlation was found between delta GTASI and delta PASI (r=-0.27, p=0.1551). GTASI decrement from T0 to T1 was statistically significant ([95%CI -26.64 to -19.56], t=-13.36, p<0.0001). Secukinumab may enter in GT therapeutic armamentarium as the first biologic IL-17 blocker in patients with concomitant moderate-to-severe plaque psoriasis.

Microsurgical endodontic treatment of the upper molar teeth and their relationship with the maxillary sinus: a retrospective multicentric clinical study.

PURPOSE: To assess the clinical and radiographic success rate of microsurgical endodontic treatment of upper molar teeth in relationship with the maxillary sinus, with 12 months follow-up. METHODS: Patients treated with microsurgical endodontic treatment of upper molar teeth in the period between 2017 and 2019 were recruited from two dental clinics according to specific selection criteria. The outcomes were determined based on clinical and radiographic results taken three, six and 12 months post-operatively, compared with those taken immediately before and after surgery. Clinical and radiographic outcomes were recorded. The distance between the most apical part of the root and of the lesion to the maxillary sinus was measured on CBCT images before the surgery. Patient-related outcomes were recorded. RESULTS: Out of 35 patients evaluated, 21 were selected according with the selection criteria for a total of 27 roots and 29 canals treated. After 12 months, 18 patients showed a complete healing whereas three demonstrated incomplete healing. Consequently, the success rate in this study was 85.7% after one year. In 28.5% (6 patients) there was a perforation of the Schneiderian membrane that didn't seem to affect the outcome. All patients kept the molar one year later. The pain level decreased significantly over the time during the first week after surgery. CONCLUSION: Microsurgical Endodontic treatment of the upper molar teeth should be considered a valid and predictable treatment option even in case of Schneiderian membrane perforation. Future clinical studies with a larger sample size are needed to compare the results obtained.

Treatment of medication-related osteonecrosis of the jaw (MRONJ). A systematic review.

OBJECTIVE: Medication-related osteonecrosis of the jaw (MRONJ) is a severe drug-related side effect mostly seen in the maxillofacial region of patients under current or previous treatment with antiresorptive and/or angiogenic agents. There is a wide range of treatment options explained in literature for the management of this condition, from conservative treatments to surgical procedures of various levels of invasiveness, which are sometimes supplemented with adjunctive therapies. The present systematic review aimed at evaluating the treatment options of MRONJ in terms of successful outcomes. MATERIALS AND METHODS: Medline, Scopus, and Cochrane databases were searched. The search was limited to clinical studies involving human subjects with at least 3 cases. There was no other limitation for language, publication date, and study design for the articles to be included. A hand search of the bibliographies of identified articles was also performed. The evaluation criterion was an improvement in the healing of the treated site after treatment procedures. RESULTS: After evaluation of the full text of the articles, 118 articles were selected for evaluation (15 platelet concentrates, 4 teriparatide, 10 laser therapy, 3 hyperbaric oxygen, 2 ozone applications, 9 conservative protocols, and 75 surgical interventions articles). The evaluated articles reported positive improvements in healing/staging of the osteonecrosis sites. CONCLUSIONS: Due to the low evidence level and the limited sample size of the studies included, the results of this review must be cautiously interpreted. However, they can be suggestive for evaluating the possible benefits of these treatment options in MRONJ management. Further prospective comparative studies with a large sample size are urgently needed to confirm the results.

Enamel matrix derivative for the treatment of partially contained intrabony defects: 12-month results.

BACKGROUND: The aim of the study was to evaluate the use of enamel matrix derivative (EMD) alone or in association with deproteinized bovine bone mineral (DBBM) for the treatment of partially contained intrabony defects. METHODS: A total of 20 two-walled intrabony defects belonging to nine patients were included. Ten defects were treated with EMD alone (test group 1) and the other 10 were treated with EMD and DBBM (test group 2), applying either modified papilla preservation technique or simplified papilla preservation technique. RESULTS: Twelve months after surgery, in the test group 1, PD was 2.8 ± 0.8 mm, REC was 2.3 ± 2.4 mm and CAL was 5.0 ± 2.8 mm, significantly reduced from baseline values (P < 0.05). Likewise, in test group 2, PD, REC and CAL reduced to 3.0 ± 0.7 mm, 3.9 ± 1.5 mm and 6.9 ± 1.1 mm respectively, from baseline values at 12 months (P < 0.05). No significant differences between groups were found. CONCLUSIONS: The results showed that the use of EMD alone and the use of a combination of EMD and DBBM for the treatment of partially contained defects showed comparable clinical and radiographic outcomes after 12 months.

Hard and soft tissue changes in the rehabilitation of the anterior maxilla with triangular shape neck implants: a retrospective clinical study with a one-year follow up.

Aim of this retrospective study was to evaluate the one-year clinical and radiographic outcomes of implants with a triangular shaped neck inserted immediately after tooth extraction in esthetic zones. Patients in which immediate postextraction implants were placed and restored in the anterior maxilla, who underwent a Cone Beam Computed Tomograpy (CBCT) at baseline and after 12-16 months were included. The socket was preserved using deproteinized bovine bone to fill the buccal gap, and a resorbable collagen membrane. One-year implant survival and prosthesis success were evaluated. Hard and soft tissue stability was assessed by measuring various parameters on CBCT images. Clinical evaluation was also performed and Pink Esthetic Score (PES) assessed. Data from baseline and one-year follow-up were statistically compared using paired tests and a significance threshold of p=0.05. Twenty patients (13 males, 7 females, mean age 50.42±11.35 years) were included. Each contributed with one implant. No implant was lost. A significant improvement in PES was detected. Excellent hard and soft tissue preservation was observed after one year of function. Immediate placement of implants with a triangular shaped neck after tooth extraction, can be a suitable solution even for areas with a high aesthetic demand, such as the anterior maxilla.

Augmentation of the atrophic maxillary sinus floor: graft stiffness, implant shape and length.

This study investigates the characteristics of load transmission to bone of alternative treatments for posterior maxilla edentulism with relatively limited available bone volume. Implant shape (conical and cylindrical), augmentation technique and the effect of bone-graft stiffness were taken into consideration. The finite element models of the atrophic sinus implanted with short implant were compared to two grafted-sinus models implanted with longer implants, engaged bicortically. Bone-graft stiffness was varied to describe different stages of graft-maturation (from short-term to long-term). Stress and load distributions due to axial and bending loads were compared on the bony structures. In the short-term, axial force is supported almost equally by the cortical layers and the trabecular core, while a bending load is mainly supported by the crestal cortical layer and secondarily by the cortical floor, the bone-graft supported a negligible load. Bicortical engagement produces higher load transfer to the cortical floor under axial load. In the long-term, as the stiffness of the bone-graft increases, the load is transferred progressively towards the grafted region, progressively unloading other structures, particularly the internal cortical layer.

Minimally-invasive osteotome sinus floor elevation combined with short implants and platelet-rich plasma for edentulous atrophic posterior maxilla: a five-year follow-up prospective study.

The aim of this study was to investigate the success of the combination of short implants, osteotome sinus floor elevation technique (OSFE) and pure platelet rich plasma (P-PRP), for the rehabilitation of atrophic posterior maxilla. Fifty-one patients were included in this study, receiving a total of 88 short implants in three different lengths (6.5 mm, 7.5 mm, 8.5 mm), depending on the residual bone height level. A total of 39 standard implants were also inserted when judged necessary, and splinted with one or more short implants in order to support a fixed prosthesis. Data were recorded in a one-year and five- year follow-ups. No statistically significant difference was found between short implants with different length, nor between short and standard length implants in terms of both bone level change and bone height. Based on the present results, the use of short implants combined with OSFE technique for the rehabilitation of atrophic posterior maxilla can be recommended.

Adjunctive glycine powder air-polishing for the treatment of peri-implant mucositis: an observational clinical trial.

OBJECTIVES: The aim of this study was to make a comparative evaluation of professional oral hygiene with or without the adjunct of glycine air-powder system for the treatment of peri-implant mucositis. METHODS: After the application of inclusion and exclusion criteria, patients were divided in two groups: in control group, patients were treated with professional oral hygiene manoeuvres (POH) while in the test group, glycine air-powder system (SGA) was adjuncted to professional oral hygiene. Probing depth (PD), bleeding index (BI) and plaque index (PI) were measured at baseline, and 3 and 6 months after the treatment. RESULTS: A total of 30 patients (15 per group) were selected for the study. In POH e SGA group, PD was, 2.86 ± 0.37 and 3.00 ± 0.36 mm at baseline, 2.90 ± 0.53 and 2.62 ± 0.50 mm after 3 months, 2.96 ± 0.56 and 2.41 ± 0.54 mm after 6 months, respectively, significantly lower in SGA group in the last follow-up visit. In both groups, both PI and BI decreased over time. CONCLUSIONS: The present reports showed that both techniques were useful for the treatment of peri-implant mucositis. In the test group (with glycine powder), a significant reduction of probing depth was observed.

Topical application of 1% chlorhexidine gel versus 0.2% mouthwash in the treatment of peri-implant mucositis. An observational study.

OBJECTIVE: The aim of this study was to compare the use of two chlorhexidine-based antimicrobial agents as an adjunct to mechanical therapy for the treatment of peri-implant mucositis. MATERIALS AND METHODS: Thirty patients with peri-implant mucositis were included in the study and randomized in two groups. In addition to mechanical therapy, group A was treated with chlorhexidine 0.2% mouthwash, while group B was treated with chlorhexidine 1% gel. Probing depth, plaque index and bleeding index were recorded at each scheduled follow-up visit: ten days, 1 month and 3 months after giving the patients the assigned formulation. Patients had to fill in a questionnaire investigating their satisfaction and ease of use of the product. RESULTS: A total of 23 patients (13 in group A and 10 in group B) attended all the follow-up visits. Chlorhexidine 0.2% mouthwash and chlorhexidine 1% gel were equally useful in the treatment of peri-implant mucositis leading to the reduction in inflammatory parameters. Probing depth decreased over time in both groups. Patients showed preference for gel formulation even if they found it more difficult to use. CONCLUSIONS: Adjunctive treatment with different chlorhexidine formulations was beneficial to the treatment of peri-implant mucositis. Besides, no differences could be found between 0.2% mouthwash and 1% gel.

Electromyographic assessment of jaw muscles in patients with All-on-Four fixed implant-supported prostheses.

This study evaluated the electromyographic (EMG) characteristics of masticatory muscles in patients with fixed implant-supported prostheses according to All-on-Four(®) principles and in control healthy dentate subjects. Twenty-six subjects aged 50-74 years were examined. Eighteen were edentulous and had been successfully rehabilitated with (i) mandibular All-on-Four(®) implant-supported fixed prostheses and maxillary complete dentures (10 patients) and (ii) mandibular and maxillary All-on-Four(®) implant-supported fixed prostheses (eight patients). Eight reference subjects had natural dentition. Surface EMG recordings of the masseter and temporalis muscles were performed during maximum voluntary teeth clenching and during unilateral gum chewing. All values were standardised as percentage of a maximum clenching on cotton rolls. During clenching, a good global neuromuscular equilibrium was found in all participants. During chewing, all groups had similar values of working-side muscle activities and of chewing frequency. No significant differences in the analysed EMG parameters were found between the patients with mandibular and maxillary All-on-Four(®) implant-supported prostheses and the reference subjects. In contrast, standardised pooled muscle activities and standardised muscular activities per cycle were larger in patients with a maxillary removable prosthesis than in control subjects (Kruskal-Wallis test, P < 0·01). Also, patients wearing a complete maxillary denture showed a poor neuromuscular coordination with altered muscular pattern and lower values of the index of masticatory symmetry than dentate control subjects (P < 0·01). EMG outcomes suggest that All-on-Four(®) implant-supported prostheses may be considered a functionally efficient treatment option for the rehabilitation of edentulous patients with reduced residual bone volume.

Clinical evaluation of an implant maintenance protocol for the prevention of peri-implant diseases in patients treated with immediately loaded full-arch rehabilitations.

OBJECTIVE: The aim of this prospective study was to assess the outcomes of an implant maintenance protocol for implants supporting a full-arch rehabilitation. MATERIALS AND METHODS: Sixty-one patients (28 women and 33 men) treated with immediately loaded full-arch rehabilitation, both mandibular and maxillary, supported by a combination of two tilted and two axial implants, were included in the study. Patients were scheduled for follow-up visits every 6 months for +2 years, then yearly up to 4 years. Each patient received professional oral hygiene treatment and detailed oral hygiene instructions. During each visit, modified plaque index, bleeding index and probing depth were assessed. The presence of peri-implant tissue inflammation was also evaluated. RESULTS: Mean observation time, considering both mandible and maxilla, was 18.3 months ranging from 6 months to 5 years. Both plaque and bleeding indexes frequency decreased over time. Probing depth was stable (2.46 ± 0.5 mm at 4 years). Only three implants were lost due to peri-implantitis (1.4% at 12 months), whereas the incidence of peri-implant mucositis was less than 10% in each considered period. CONCLUSIONS: The adoption of a systematic hygienic protocol is effective in keeping low the incidence of peri-implant mucositis as well as in controlling plaque accumulation and clinical attachment loss.

[Immediate implant placement in endodontically infected sites: an alternative treatment for compromised teeth].

In certain clinical conditions when endodontic treatment is either impractical or unlikely to improve the previous results, tooth extraction and replacement with a dental implant becomes a viable alternative. Although the presence of active infection has long been considered a major contraindication to the insertion of implants immediately following tooth extraction, several articles assessing this treatment modality reported excellent and promising results. The aim of this literature review is to evaluate and discuss the clinical outcome of implants placed immediately following extraction in endodontically infected sockets. A Medline and EMBASE search was performed to identify articles published from 1966 to 2010 using the keywords "dental implants", "immediate implant", "extraction socket", "infected teeth", "infected site", "infected socket". No restrictions were placed regarding the study design. Only clinical articles with at least 6 months of follow-up were included. The available relevant literature concerning this topic was limited, and based on relatively low level of evidence study designs with limited follow-up periods. However, the data analysis of the selected articles showed that an immediate implant insertion in endodontically infected sites following tooth extraction and careful debridement of the socket, could be a predictable viable technique. Additional large scaled, well-designed studies are required in order to further assess the clinical applications of this treatment alternative.

A modified technique for using the endoscope in periradicular surgery. A case report.

The aim of this case report was to describe a modified endoscopic technique for enhancing visualization in endodontic microsurgery. Tooth treated surgically showed a periradicular lesion of strictly endodontic origin. Following the reflection of a full mucoperiosteal papilla base incision flap, surgical access to the root was made through the cortical bone. The periradicular lesion was curetted, root-end was resected, and root-end cavity was prepared with a zirconium nitrate tip driven by ultrasonic device unit. Finally zinc oxide EBA-reinforced cement root-end filling was placed. Root-end management procedure was performed using an endoscope. Diving the endoscope lens in the bone cavity filled with saline solution contributed to improve visualization and keep clear the lens. Following clinical and radiographic assessment at 12 months postsurgery, the case was evaluated successfully. Thus, in conclusion, the endoscope provided excellent visualization of the surgical field during root-end cavity preparation.

Immediate loading in the fully edentulous maxilla without bone grafting: the V-II-V technique.

AIM: The aim of this prospective study was to evaluate a new surgical approach for the immediate rehabilitation of fully edentulous maxilla without any type of bone grafting. METHODS: The technique named ''V-II-V'' consists of an immediately loaded full-arch bridge supported by six implants. Two distal implants engage the posterior wall of the maxillary sinus, being tilted 30-45 degrees relative to the occlusal plane. Two other tilted implants engage the anterior wall of the sinus, and finally two axial implants are inserted in the anterior maxilla. An acrylic provisional restoration is delivered within 4 hours of implant placement. At each follow-up, plaque and bleeding indexes were scored, marginal bone level change around tilted and axial implants were evaluated, and a questionnaire was compiled to assess patient's satisfaction for function and aesthetics. RESULTS: Twenty-one patients were rehabilitated. A total of 126 implants were inserted. Nineteen prostheses were in function for more than 12 months. The average follow-up was 20 months (range 4-35 months). No implant failure occurred to date, leading to 100% survival rate and 100% prosthesis success. No complication was recorded. Peri-implant bone loss at axial and tilted fixtures was similar at one year, being 0.8 mm (SD 0.4, N.=28) and.0.9 mm (SD 0.5 mm, N.=56) respectively (P>0.05). RESULTS: The ''V-II-V'' technique is a viable treatment modality for the immediate rehabilitation of the edentulous maxilla, avoiding bone grafting or sinus augmentation. Long-term evaluation is needed to confirm these encouraging preliminary

Surgical versus non-surgical endodontic re-treatment for periradicular lesions.

BACKGROUND: Though success rates of endodontic initial treatment have been improving over the years, persistence of periapical disease is far from being a rare condition. The most common therapeutical options for the re-treatment of teeth with periapical pathosis are non-surgical orthograde treatment and surgical treatment. Selection between alternative treatments should be based on assessment of respective benefits (mainly healing) and risks from studies consistent with a high level of evidence. OBJECTIVES: To test the null hypothesis of no difference in outcome between surgical and non-surgical therapy for endodontic re-treatment of periradicular lesions. SEARCH STRATEGY: The Cochrane Oral Health Group Trials Register, CENTRAL, MEDLINE and EMBASE were searched with appropriate search strategies. Handsearching included eight dental journals. The bibliographies of relevant clinical trials and relevant articles were checked for identifying studies outside the handsearched journals. Seven manufacturers of instruments in the field of endodontics or endodontic surgery or both, as well as the authors of the identified randomised controlled trials (RCTs) were contacted in order to identify unpublished or ongoing RCTs. No language restriction was placed. The last electronic search was conducted on 3rd April 2007. SELECTION CRITERIA: All RCTs about re-treatment of teeth with periapical pathosis in which both surgical and non-surgical approaches were used and having a follow up of at least 1 year were considered for the analysis. DATA COLLECTION AND ANALYSIS: A quality assessment of the included RCTs was carried out and the authors were contacted for missing information. We independently extracted the data in duplicate. We followed the Cochrane Oral Health Group's statistical guidelines. MAIN RESULTS: Three RCTs were identified, two of them reporting different data from the same clinical study. The risk of bias was judged as moderate for one study and high for the other one. 126 cases were followed up for at least 1 year, and 82 had a follow up of 4 years. At the 1-year follow up the success rate for surgical treatment was slightly better than non-surgical (risk ratio (RR) 1.13; 95% confidence interval (CI) 0.98 to 1.30). When the follow up was extended to 4 years (only one RCT made it) the outcome for the two procedures became similar. AUTHORS' CONCLUSIONS: The finding that healing rates can be higher for cases treated surgically as compared to those treated non-surgically, at least in the short term, is based on two RCTs only. A single RCT reported that in the medium to long term healing rates for the two procedures are very similar. There is currently scarce evidence for a sound decision making process among alternative treatments for the re-treatment of a periradicular pathosis. More well-designed RCTs should be performed with follow up of at least 4 years, and with a consistent sample size, to detect a true difference in the long term between the outcomes of the two alternative treatments, if any exist.