Apicectomía de Primer Molar Inferior. Revisión de Literatura y Reporte de Caso

La apicectomía consiste en la amputación de la fracción apical de la raíz de un diente lesionado y se considera la última opción terapéutica para mantener el diente afectado en boca. Con el objetivo de dilucidar el potencial terapéutico de la técnica quirúrgica, en el presente estudio presentamos el reporte de caso de un paciente con cuadro de hiperestesia asociada al nervio alveolar inferior debido a sobreobturación de la raíz mesial de un primer molar inferior izquierdo. Para resolver el caso realizamos apicectomía mediante abordaje convencional acompañado de medicación empírica enfocada a resolver cuadros de parestesia asociada al procedimiento. Durante los controles posteriores al procedimiento quirúrgico se pesquisa ausencia de parestesia y sintomatología dolorosa, por lo que consideramos la apicectomía como una buena opción de tratamiento en casos de sobreobturación apical que no pueden solucionarse mediante tratamiento no quirúrgico.

Apicoectomy consists of the amputation of the apical fraction of the root of an injured tooth and is considered the last therapeutic option to keep the affected tooth in the mouth. With the aim of elucidating the therapeutic potential of the surgical technique, in this study we present the case report of a patient with hyperesthesia associated with the inferior alveolar nerve due to overfilling of the mesial root of a left lower first molar. To solve the case we performed apicoectomy by conventional approach accompanied by empirical medication focused on resolving paresthesia associated to the procedure. During the controls after the surgical procedure we found absence of paresthesia and painful symptomatology, so we consider apicoectomy as a good treatment option in cases of apical overfilling that cannot be solved by non-surgical treatment.

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

Abstract 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.

Resumo O objetivo deste estudo foi avaliar o efeito da apicectomia realizada com broca ou inserto ultrassônico na adaptação do material obturador á dentina do canal radicular. Vinte incisivos inferiores humanos extraídos foram selecionados e preparados com o sistema ProDesign Logic até o diâmetro 40/.05. Os canais radiculares foram obturados com Bio-C Sealer (Angelus, PR, Brasil) por meio da técnica de cone único e foram armazenados em estufa a 37ºC e umidade relativa de 95% por 7 dias. Após esse período, foi realizada apicectomia dos 3 milímetros apicais utilizando broca Endo-Z (Maillefer - Dentsply) ou inserto ultrassônico BladeSonic (Helse Ultrasonic, Santa Rosa de Viterbo, Brasil) (n=10). Os espécimes foram escaneados por meio de microtomografia computadorizada (micro-CT; SkyScan 1176) com tamanho de voxel de 8,74 µm após obturação e após apicectomia. Please, correct this sentece to O percentual de falhas na interface entre o material obturador e a parede dentinaria foi avaliado nos 4 mm apicais da raiz apos apicectomia, alem do tempo de corte para ambos dispositivos. Os dados obtidos foram submetidos aos testes t pareado e não pareado (α = 0,05). Endo-Z e Bladesonic aumentaram o percentual de vazios entre o material obturador e a parede da dentina após apicectomia (p<0.05), sendo semelhantes entre si (p>0.05). Endo-Z demonstrou menor tempo para realizar apicectomia em comparação com Bladesonic (p<0.05). Apicectomias com Endo-Z ou Bladesonic podem prejudicar a interface material obturador/dentina, sendo a broca Endo-Z mais rápida que a ponta ultrassônica Bladesonic.

Regeneration of a large bony lesion with advanced-platelet rich fibrin: case report / Regeneración de una lesión ósea de gran tamaño con fibrina rica en plaquetas: reporte de caso

Introduction: This case report analyzes the regeneration potential of advanced-platelet rich fibrin (A-PRF) in large bony lesions. Advanced-platelet rich fibrin provides various growth factors which aids in faster healing. Materials and Methods: Patient presented with peri-apical radiolucency. CBCT showed bony radiolucency in teeth 31, 32, 41, 42. A full mouth mucoperiosteal flap was raised and a cyst lining was enucleated. Apicoectomy was done with respect to 31, 32, 41, 42 along with and retrograde with a preparation of APRF clots were placed in the bony cavity. Results: Post-op CBCT at 6 months showed a significant difference in size and bone density of the lesion. Conclusions: Advanced-platelet rich fibrin has shown promising results in reducing the size of bony defect and periapical lesion in this case.

Introducción: Este caso clínico demuestra el potencial de regeneración de la fibrina rica en plaquetas avanzada (A-PRF) en lesiones óseas de gran tamaño. La fibrina rica en plaquetas avanzada proporciona varios factores de crecimiento que ayudan a una curación más rápida. Materiales y Métodos: El paciente se presentó con radiolucencia periapical. Tomografía computarizada de haz cónico mostró radiolucencia ósea en los dientes 31, 32, 41, 42. Se levantó un colgajo mucoperióstico de boca completa y se enucleó el revestimiento del quiste. Se realizó apicectomía con respecto a 31, 32, 41, 42, y se colocó una preparación de APRF se colocaron coágulos en la cavidad ósea. Resultados: La tomografía computarizada de haz cónico postoperatorio a los 6 meses mostró una diferencia significativa en el tamaño y la densidad ósea de la lesión. Conclusión: La fibrina rica en plaquetas avanzada ha mostrado resultados prometedores en la reducción del tamaño del defecto óseo y la lesión periapical en este caso.

Application of Platelet?Rich Fibrin and Freeze?Dried bone Allograft Following Apicoectomy: A Comparative Assessment of Radiographic Healing

Background: Apicoectomy conceptualizes surgically maintaining a tooth with an endodontic lesion that cannot be resolved by conventional endodontic (re?) treatment. To achieve this, continuous improvement in surgical techniques, materials and instruments is being done to enhance the outcome of periapical endodontic surgeries. The purpose of this study was to compare, radiographically, the healing kinetics of platelet?rich fibrin (PRF) and mineralized freeze?dried bone allograft (FDBA) in patients undergoing apicoectomy. Materials and Methods: Nineteen patients (aged 18–40 years) were included in the study and randomly assigned to groups A or B, where they received PRF or FDBA, respectively. Following apicoectomy, PRF gel and FDBA graft were prepared and placed in the osseous defect followed by placement of PRF membrane for graft stabilization and flap closure. Radiographic follow?up was done at the 1st, 3rd, 6th and 12th months for evaluation of healing using Molven’s criteria. Statistical analysis was done with Pearson’s and McNemar’s Chi?square tests. Results: A highly significant difference (P = 0.002) in radiographic healing was observed at 6 months. Complete healing was observed in 50% of cases in Group A whereas in Group B, none of the cases presented with complete radiographic healing. However, at the end of 12 months, complete radiographic healing was observed in both groups. Conclusion: Our data suggest that PRF accelerates bone healing as compared to FDBA and is both time and cost?efficient.

Regeneración ósea con fibrina rica en plaquetas en una cirugía apical / Bone regeneration with platelet-rich fibrin in apical surgery

Introducción: La fibrina rica en plaquetas es una membrana o coágulo de fibrina, que brinda gran cantidad de factores de crecimiento, leucocitos y citoquinas. Esta es una buena alternativa para promover una mejor cicatrización, además de potenciar otros biomateriales con el fin de condicionar una mejor regeneración y en un menor período de tiempo. Su fácil preparación y manipulación, a diferencia de otros preparados plaquetarios, hacen que pueda ser usada en la práctica clínica diaria. Objetivo: Mostrar el manejo de una cirugía apical con aplicación de fibrina rica en plaquetas y su resultado clínico. Presentación de caso: Paciente de sexo femenino, de 47 años, con absceso apical crónico a nivel del segundo premolar superior derecho. Radiográficamente se observó una lesión apical persistente, el instrumento fracturado en uno de los conductos radiculares, el material de obturación sobreextendido y retenedor intrarradicular. Se decidió realizar cirugía apical con obturación retrógrada y relleno óseo en combinación con fibrina rica en plaquetas. Resultados: El paciente evolucionó de forma favorable y se evidenció cicatrización ósea en desarrollo, sin complicaciones. Conclusiones: La utilización de fibrina rica en plaquetas, en combinación de relleno óseo durante la cirugía endodóntica, es una buena alternativa por sus propiedades de regeneración ósea(AU)

Introduction: Platelet-rich fibrin is a fibrin membrane or clot, which provides a large amount of growth factors, leukocytes and cytokines. This is a good alternative to help better healing, in addition to enhancing other biomaterials in order to condition better regeneration and in a shorter period of time. Its easy preparation and handling, unlike other platelet preparations, mean that it can be used in daily clinical practice. Objective: To show the management of an apical surgery with the application of platelet-rich fibrin and its clinical result. Case report: This is the case of a female patient, 47 years old, with chronic apical abscess at the level of the upper right second premolar. Radiographically, a persistent apical lesion was observed, the instrument fractured in one of the root canals, the obturation material overextended, and the intraradicular retainer. It was decided to perform apical surgery with retrograde obturation and bone filling in combination with platelet-rich fibrin. Results: The patient evolved favorably and evidenced bone healing in development, without complications. Conclusions: The use of platelet-rich fibrin, in combination with bone filler during endodontic surgery, is a good alternative due to its bone regeneration properties(AU)

Quiste periapical: diagnóstico y tratamiento / Periapical cyst: diagnosis and treatment

Los quistes periapicales o radiculares representan una de las patologías periapicales más frecuentes dentro del grupo de las lesiones quísticas de los maxilares. Son el resultado de la extensión de proce- sos inflamatorios-infecciosos. Su diagnóstico sigue siendo un desafío para el profesional odontológico, quien debe diferenciarlo de otros procesos inflama- torios periapicales. El objetivo del presente artículo es presentar, apoyado en una revisión de la literatura, el caso clínico de un paciente masculino de 38 años de edad que se presentó a la consulta por leve tume- facción indolora en zona anterosuperior del maxilar. A la inspección se observó borramiento de la región del surco vestibular a nivel de piezas dentarias 1.1, 1.2 y 1.3, de color rojizo con crepitación de la tabla ósea vestibular a la palpación. La tomografía de haz cónico mostró lesión osteolítica, extendida desde zona apical de la pieza dentaria 1.4 hasta zona del elemento dentario 1.1. Se realizó la extirpación de la lesión y api- cectomía. El estudio histológico corroboró el diagnós- tico presuntivo de quiste periapical. Los controles a distancia mostraron buena evolución del tratamiento. Se concluyó en la importancia de realizar un correcto diagnóstico clínico e imagenológico para la selección de un adecuado tratamiento según el caso (AU)

Periapical or radicular cysts represent one of the most frequent periapical pathologies within the group of cystic lesions of the jaws. They are the result of the spread of inflammatory-infectious processes. Its diagnosis continues to be a challenge for the dentist, who must differentiate it from other periapical inflammatory processes. The objective of this article is to present, supported by a review of the literature, the clinical case of a 38-year-old male patient who presented to the consultation due to mild painless swelling in the anterosuperior maxilla. Upon inspection, effacement of the vestibular sulcus region was observed at the level of teeth 1.1, 1.2 and 1.3, reddish in color with crepitation of the buccal bone table on palpation. Cone beam tomography showed an osteolytic lesion that extended from the apical area of tooth 1.4 to area of tooth 1.1. Excision of the lesion and apicoectomy were performed. The histological study corroborated the presumptive diagnosis of periapical cyst. Remote controls showed a good evolution of the treatment. It was concluded on the importance of carrying out a correct clinical and imaging diagnosis for the selection of an adequate treatment according to the case (AU)

Microcirugía endodóntica con planificación digital y guía quirúrgica: caso clínico / Endodontic microsurgery with digital planning and surgical guide: a clinical case

La microcirugía endodóntica (MCE) es una alternativa al tratamiento no quirúrgico de la periodontitis apical persistente. Por su evolución junto a los avances tecnológicos, la incorporación de la tomografía computarizada de haz cónico (CBCT), la tecnología de impresión tridimensional (3D) y las guías quirúrgicas diseñadas con software asistido por computadora, han permitido implementar la planificación digital llevada a cabo en el acto quirúrgico. El objetivo de este informe es describir un caso clínico de MCE guiada, con un protocolo de diseño digital y el uso de una guía quirúrgica impresa en resina biocompatible, diseñada con precisión de acuerdo con las mediciones de CBCT preoperatorias. Se diseñó un kit de trefinas con "sleeves" (Neokings) para realizar la osteotomía y resección de los últimos 3 mm apicales direccionados por la guía quirúrgica. La tabla cortical intacta se recuperó y se utilizó como injerto junto con plasma rico en fibrina. La guía de cirugía apical permite al profesional lograr ubicar con precisión los tejidos objetivos de la cirugía y acortar el tiempo del procedimiento. Un control CBCT inmediato mostró la planificación exacta en 3D del sitio quirúrgico (AU)

Usos del láser en la terapia endodóntica: revisión de la literatura / Laser uses in endodontic therapy: literature review

Últimamente, el uso del láser en endodoncia ha ganado aceptación llegando a considerarse como un complemento a la terapia endodóntica, la cual tiene como objetivo realizar una efectiva conformación, limpieza y desinfección del sistema de canales radiculares (SCR), permitiendo una eliminación eficaz de microorganismos presentes, y así prevenir la reinfección del canal. Se han adoptado diferentes métodos de aplicación del láser para mejorar la desinfección del SCR, los cuales podrían ser eficaces para reducir la población microbiana presentes al interior de los canales, por medio de la activación del irrigante utilizado. El empleo de láser también podría ser útil en procedimientos endodónticos quirúrgicos los cuales tienen por objetivo mantener el diente y sus raíces cuando el tratamiento convencional ha fallado, los efectos positivos del láser se centrarían en el descenso de la inflamación y del aumento de volumen, además de la disminución de la filtración de los materiales de sello ortógrado en dientes apicectomizados. Otro de los usos de láser en esta materia está relacionado con el manejo del dolor post-terapia endodóntica, el que se ha visto ser prometedor. Se definen dos tipos de láseres: de baja potencia, que produce una acción bioestimulante, analgésica y antiinflamatoria de los tejidos biológicos, utilizada además en procesos de descontaminación del SCR, y de alta potencia o láser quirúrgico, con el que se pueden realizar incisiones, exéresis, realizando funciones de corte y coagulación.

Lately, the use of laser in endodontics has gained acceptance, being considered as a complement to endodontic therapy, which aims to carry out an effective shaping, cleaning and disinfection of the root canal system (RCS), allowing an effective elimination of microorganisms present, and thus prevent reinfection of the canal. Different laser application methods have been adopted to improve the disinfection of the RCS, which could be effective in reducing the microbial population present inside the canals, by activating the irrigant used. The use of laser could also be useful in surgical endodontic procedures which aim to maintain the tooth and its roots when conventional treatment has failed, the positive effects of laser would focus on reducing inflammation and increasing volume, in addition of the reduction in the filtration of orthograde seal materials in apicoectomized teeth. Another use of laser in this area is related to post-endodontic therapy pain management, which has shown promise. Two types of lasers are defined; low-power, which produces a biostimulant, analgesic and anti-inflammatory action of biological tissues, also used in RCS decontamination processes, and high-power or surgical laser, with which incisions, excision, performing cutting functions and coagulation.

Apicotomia associada ao tracionamento ortocirúrgico em dente com dilaceração radicular / Apicotomy associated with orto-surgical treatment in tooth with a root dilaceration

Introdução: A apicotomia é uma técnica, que vem sendo utilizada em dentes com dilaceração radicular acentuada, com o intuito de liberar a porção do dente impactada e, dessa forma, permitir seu reposicionamento na arcada dentária. Este trabalho tem como objetivo apresentar um relato de caso clínico do manejo ortocirúrgico de tracionamento ortodôntico associado à apicotomia em dente incluso com dilaceração radicular acentuada. Relato de caso: O paciente foi encaminhado para o serviço de bucomaxilofacial para exodontia do elemento incluso após insucesso de tracionamento ortocirúrgico, em que se verificou, ao exame radiográfico periapical, dente incluso com dispositivo ortodôntico e dilaceração radicular importante. Diante disso, realizou-se, sob anestesia local, a apicotomia e instalação do dispositivo ortodôntico. O paciente evoluiu bem, e, após 8 meses, o elemento dentário encontrava-se em posição oclusal e em função mastigatória. Considerações finais: Assim, a técnica da apicotomia mostra-se eficaz como alternativa ao insucesso do tracionamento ortodôntico tradicional, sendo uma técnica mais conservadora que a exodontia, necessitando de conhecimento teórico e domínio técnico do profissional... (AU)

Introduction: Apichotomy is a technique that has been used in teeth with severe root laceration in order to release the impacted tooth portion and thus allow its repositioning of the tooth in the dental arch. The aim of this paper is to present a clinical case report of orthosurgical orthodontic traction management associated with apichotomy in an included tooth with severe root laceration. Case report: The patient was referred to the Oral and Maxillofacial Service for extraction of the included element after ortho-surgical traction failure, which was verified by periapical radiographic examination, tooth included with orthodontic device and significant root laceration. Thus, under local anesthesia, apichotomy and orthodontic device installation were performed. The patient progressed well, and after 8 months the dental element was in occlusal position and in masticatory function. Final considerations: Thus, the apichotomy technique is effective as an alternative to the failure of traditional orthodontic traction, being a more conservative technique than extraction and requiring theoretical knowledge and technical mastery of the Professional... (AU)

Endodontic Surgery Associated with Guided Tissue Regeneration Technique: Case Report / Cirurgia Parendodôntica Associada à Técnica de Regeneração Tecidual Guiada: Relato de Caso

Non-surgical endodontic retreatment should always be the first option for reintervention when the initial endodontic treatment fails. The surgical treatment, called periradicular surgery, will be the procedure of choice when there is no success after the conventional endodontic retreatment. The purpose of this article is to describe clinical case of endodontic surgery, associated with guided tissue regeneration (GTR). A male patient, 24 years old, was referred for endodontic surgery on tooth 12 after two unsuccessful endodontic interventions. During the surgery, osteotomy, lesion curettage, apicectomy, retrograde obturation with Mineral Trioxide Aggregate (MTA), and filling of the bone failure with lyophilized bone and reabsorbable collagen membrane were performed. After six months of follow-up, the patient did not present any type of painful symptomatology. The endodontic surgery, associated with a technique of guided tissue regeneration, was efficient to solve this clinical case. (AU)

O retratamento endodôntico não cirúrgico deve sempre ser a primeira opção de reintervenção quando o tratamento endodôntico inicial falha. Já o tratamento cirúrgico, ou cirurgia parendodôntica, será o procedimento de escolha quando não há sucesso após o retratamento endodôntico convencional. O objetivo deste artigo é descrever um caso clínico de cirurgia parendodôntica, associada à regeneração tecidual guiada (RTG). O paciente, gênero masculino, 24 anos, foi encaminhado para cirurgia parendodôntica no dente 12 após duas intervenções endodônticas sem sucesso. Durante a cirurgia foram realizadas manobras de osteotomia, curetagem da lesão, apicectomia, obturação retrógrada com Mineral Trióxido Agregado (MTA), além de preenchimento da falha óssea com osso liofilizado e membrana de colágeno reabsorvível. Após seis meses de acompanhamento do caso, o paciente não apresentou nenhum tipo de sintomatologia dolorosa. A cirurgia parendodôntica, associada à técnica de regeneração tecidual guiada, foi eficiente para solucionar este caso clínico. (AU).

Extrusion of Endodontic Material to the Maxillary Sinus: Avoidable Intercurrence? / Extrusión de Material Endodóntico al Seno Maxilar: ¿Intercurrencia Evitable?

ABSTRACT: The objective of this study is to discuss and analyze whether extrusion of endodontic material constitutes avoidable intercurrence, discussing the clinical, ethical and legal implications. Patient LSR, 31 years old, female, attended a dental consultation complaining of pain in the second left maxillary premolar (tooth 25). Radiographically, a single root canal and thickening of the periodontal ligament associated with extravasation of 8 mm of gutta percha to the maxillary sinus were observed. The first endodontic session aimed to performing the desobturation, root canal preparation and intracanal medication placement. The root canal obturation was performed in the second session. Was carried out an apical surgery that removed 2 mm from the root apex and also performed the covered with a collagen membrane. A 22 months follow-up revealed a tooth function, absence of painful symptomatology or infection, and radiographically normal periodontal ligament and bone neoformation. The second single-root premolar is the type of premolar with less distance with the floor of the maxillary sinus. In this case, the extrusion of the obturator material occurred due to the superinstrumentation of the root canal associated with the proximity of the root with the membrane of the maxillary sinus. From the ethical and legal point of view, the patient has the right to be informed about any intercurrences that may arise during or after the treatment, and the informed consent form is essencial. This document will allow the patient to make a decision about performing an endodontic treatment in which the risk of an accident or complication is imminent or that treatment failure is already expected. It is important that professionals make appropriate diagnosis and treatment plan for each case, since this conduct may avoid clinical intercurrences. In addition, if the intercurrences occur, the patient should be advised of how to proceed.

RESUMEN: El objetivo de este estudio fue discutir y analizar si la extrusión de material endodóntico constituye una intercurrencia evitable, discutiendo las implicaciones clínicas, éticas y legales. Paciente LSR, de 31 años de edad, mujer, asistió a una consulta dental quejándose de dolor en el segundo premolar maxilar izquierdo (diente 25). Radiográficamente, se observó un solo conducto radicular y engrosamiento del ligamento periodontal asociado con la extravasación de 8 mm de gutapercha al seno maxilar. La primera sesión de endodoncia tuvo como objetivo realizar la desobturación, la preparación del conducto radicular y la colocación de medicación intracanal. La obturación del conducto radicular se realizó en la segunda sesión. Se llevó a cabo una cirugía apical que extrajo 2 mm del ápice de la raíz y también se realizó el recubrimiento con una membrana de colágeno. Un seguimiento de 22 meses reveló función dental, ausencia de sintomatología dolorosa o infección y ligamento periodontal radiográficamente normal y neoformación ósea. El segundo premolar de una sola raíz es el tipo de premolar con menos distancia con el piso del seno maxilar. En este caso, la extrusión del material obturador se produjo debido a la superinstrumentación del conducto radicular asociada con la proximidad de la raíz con la membrana del seno maxilar. Desde el punto de vista ético y legal, el paciente tiene derecho a ser informado acerca de cualquier inter-ocurrencia que pueda surgir durante o después del tratamiento, y el formulario de consentimiento informado es esencial. Este documento le permitirá al paciente tomar una decisión sobre la realización de un tratamiento de endodoncia en el que el riesgo de un accidente o complicación sea inminente o de que ya se espera un fracaso del tratamiento. Es importante que los profesionales realicen un diagnóstico y un plan de tratamiento adecuados para cada caso, ya que esta conducta puede evitar las intercurrencias clínicas. Además, si se producen intercurrencias, se debe informar al paciente sobre cómo proceder.

Reimplante intencional como alternativa ao implante dentário: relato de caso com 10 anos de proservação / Intentional replantation as an alternative to dental implant: a 10-years follow-up case report

Objetivo: apresentar o relato de um caso de tratamento viável para molar inferior permanente endodonticamente tratado que apresentou sintomatologia após 6 meses do tratamento endodôntico. Uma vez que retratamento endodôntico ou cirurgia parendodôntica não eram indicados, o reimplante intencional foi a técnica escolhida. Relato de caso: uma hora antes do procedimento, o paciente fez bochecho com gluconato de clorexidina a 0,12% e foi preparado para cirurgia com anestesia dos nervos alveolar inferior e lingual, realizada com mepivacaína 2% contendo 1:100.000 de adrenalina. O procedimento teve início com extração menos traumática possível, envolvendo-se imediatamente o dente extraído em gaze umedecida com soro fisiológico, enquanto as raízes foram avaliadas para presença de fraturas, seguida da apicectomia. As cavidades foram retroinstrumentadas com broca de alta rotação sob irrigação com soro fisiológico e, para a retro-obturação, foi utilizado agregado de trióxido mineral (MTA) branco. Imediatamente, o dente foi reposicionado no alvéolo e estabilizado por suturas com fio de seda 4-0. Após um ano, o paciente retornou para controle radiográfico e clínico, o qual não revelou mais resposta à percussão vertical. Após 10 anos, a imagem radiográfica mostra reparo apical, sem indícios de reabsorção radicular ou lesão periapical. Conclusão: o exame clínico, associado à ausência dor e mobilidade normal do dente, confirmou o sucesso do tratamento, indicando esse como uma alternativa válida quando o implante não for acessível para o paciente. Essa técnica pode ajudar a restaurar a função de um dente original, em vez de substituí-lo por prótese ou implante dentário (AU).

Objective: This case report shows a successful viable treatment for an endodontically treated permanent mandibular molar which presented clinical symptoms 6 months after the endodontic treatment. Since endodontic retreatment or paraendodontic surgery were not indicated, the chosen technique was intentional replantation. Case Report: One hour before the procedure, the patient rinsed his mouth with chlorhexidine gluconate 0.12%. The patient was prepared for surgery and profound inferior alveolar and lingual nerve block anesthesia was achieved with 2% mepivacaine containing 1/100,000 adrenaline. The procedure started with the least traumatic extraction as possible and immediately wrapping the extracted tooth in physiological saline-moistened gauze, while the roots were evaluated for vertical fractures, followed by apicoectomy. The cavities were retro-prepared with high-speed bur under irrigation with physiological saline and white mineral trioxide aggregate (MTA) was used for retrofilling. Immediately, the tooth was repositioned in the alveolus. Two 4-0 silk sutures were used to suture and stabilize the tooth. After one year, the patient returned for radiographic and clinical control, which revealed no more response to vertical percussion. After 10 years, the images show radiographic apical repair, without evidence of root resorption or periapical lesion. Conclusion: Clinical examination associated with the reported absence of pain and normal mobility confirmed the procedure's success, indicating this treatment as a valid alternative when an implant is not viable. This technique may help restore an original tooth to function instead of replacing it with a prosthetic or a dental implant (AU).

Apicectomia no tratamento de reabsorção radicular causada por terceiro molar incluso: relato de caso / Apicoectomy in the treatment of radicular resorption caused by third molar impacted: case report

Introdução: A presença dos terceiros molares pode trazer consequências para estruturas em sua volta de acordo com sua posição e profundidade intraóssea, sendo o principal método terapêutico, para a reabsorção radicular externa, a eliminação da causa. Dessa forma, o presente trabalho tem como objetivo relatar um caso de apicectomia associada ao tratamento endodôntico como alternativa de preservação de segundo molar, com reabsorção radicular causada pelo terceiro molar impactado. Relato do caso: Paciente do sexo masculino procurou atendimento para consulta odontológica preventiva, e, após exame radiográfico de rotina, observou-se inclusão horizontal do elemento 38 e imagem sugestiva de reabsorção severa da raiz distal do dente 37, a qual foi confirmada após tomografia computadorizada de feixe cônico. O plano de tratamento consistiu em tratamento endodôntico prévio do dente 37, exodontia do dente 38 e apicectomia distal do dente 37. O paciente evoluiu bem, sem intercorrências e com manutenção da função e estética do elemento envolvido. Considerações Finais: A reabsorção da raiz distal do segundo molar inferior em função do terceiro molar impactado não é tão incomum, e para reabsorções mais severas, o tratamento endodôntico prévio com MTA seguido da apicectomia tem-se demonstrado uma combinação eficaz, com bom prognóstico e resultados satisfatórios... (AU)

Introduction: The presence of third molars may have consequences for structures around them according to their position and intraosseous depth, and the main therapeutic method for external root resorption is elimination of the cause. Thus, the present study aims to report a case of apicectomy associated with endodontic treatment as an alternative for the preservation of the second molar with root resorption caused by impacted third molar. Case report: A male patient sought care for a preventive dental visit, and after a routine radiographic examination, a horizontal inclusion of the element 38 was observed and an image suggestive of severe resorption of the distal root of the tooth 37, which was confirmed after computed tomography cone-bean. The treatment plan consisted of prior endodontic treatment of tooth 37, extraction of tooth 38 and distal apicoectomy of tooth 37. The patient progressed well, without intercurrences and with maintenance of the function and esthetics of the involved element. Final Considerations: Resorption of the distal root of the second lower molar in consequence of impacted third molar is not uncommon, and for more severe resorptions, previous endodontic treatment with MTA followed by apicectomy has shown an effective combination with good prognosis and satisfactory results... (AU)

Natural bioceramics: our experience with changing perspectives in the reconstruction of maxillofacial skeleton

OBJECTIVES: Various bone graft substitute materials are used to enhance bone regeneration in the maxillofacial skeleton. In the recent past, synthetic graft materials have been produced using various synthetic and natural calcium precursors. Very recently, eggshell-derived hydroxyapatite (EHA) has been evaluated as a synthetic bone graft substitute. To assess bone regeneration using EHA in cystic and/or apicectomy defects of the jaws through clinical and radiographic evaluations. MATERIALS AND METHODS: A total of 20 patients were enrolled in the study protocol (CTRI/2014/12/005340) and were followed up at 4, 8, 12, and 24 weeks to assess the amount of osseous fill through digital radiographs/cone-beam computed tomography along with clinical parameters and complications. Wilcoxon matched pairs test, means, percentages and standard deviations were used for the statistical analysis. RESULTS: The sizes of the lesions in the study ranged from 1 to 4 cm and involved one to four teeth. The study showed significant changes in the formation of bone, the merging of material and the surgical site margins from the first week to the first month in all patients (age range, 15-50 years) irrespective of the size of the lesions and the number of teeth involved. Bone formation was statistically significant from the fourth to the eighth week, and the trabecular pattern was observed by the end of 12 weeks with uneventful wound healing. CONCLUSION: EHA showed enhancement of bone regeneration, and healing was complete by the end of 12 weeks with a trabecular pattern in all patients irrespective of the size of the lesion involved. The study showed enhancement of bone regeneration in the early bone formative stage within 12 weeks after grafting. EHA is cost effective and production is environment friendly with no disease transfer risks. Thus, natural bioceramics will play an important role in the reduction of costs involved in grafting and reconstruction.

A new minimally invasive guided endodontic microsurgery by cone beam computed tomography and 3-dimensional printing technology

Endodontic microsurgery is defined as the treatment performed on the root apices of an infected tooth, which was unresolved with conventional root canal therapy. Recently, the advanced technology in 3-dimensional model reconstruction based on computed tomography such as cone beam computed tomography has opened a new avenue in application of personalized, accurate diagnosis and has been increasingly used in the field of dentistry. Nevertheless, direct intra-oral localization of root apex based on the 3-dimensional information is extremely difficult and significant amount of bone removal is inevitable when freehand surgical procedure was employed. Moreover, gingival flap and alveolar bone fenestration are usually required, which leads to prolonged time of surgery, thereby increasing the chance of trauma as well as the risk of infection. The purpose of this case report is to present endodontic microsurgery using the guide template that can accurately target the position of apex for the treatment of an anterior tooth with calcified canal which was untreatable with conventional root canal therapy and unable to track the position of the apex due to the absence of fistula.

Uso del plasma rico en fibrina en endodoncia para regeneración ósea. Reporte de dos casos clínicos / Use of fibrin-rich plasma in bone-repair endondontic procedures. Report of two clinical cases

Resumen: Introducción: Las lesiones periapicales crónicas producen defectos óseos en la zona apical del diente comprometido. La terapia estándar requiere de una osteotomía, remoción del ápice, un profuso curetaje para remover el tejido infectado y granulomatoso, dejando un defecto óseo. Reporte de casos: Dos pacientes con lesiones periapicales fueron sometidos a una apicectomía donde se les colocó como relleno óseo plasma rico en fibrina. El tratamiento fue efectivo, ya que en 30 días se observó radiográficamente una zona radiopaca sugiriendo una formación ósea. Conclusión: La utilización de plasma rico en fibrina para rellenos óseos después de cirugías paraendodónticas podría ser una buena alternativa a los rellenos óseos comerciales por tener propiedades óseo-inductoras.

Abstract Introduction: Chronic periapical lesions cause bone defects in the apical area of compromised teeth. Standard therapy requires osteotomy, apex removal and profuse curettage to remove granulomatous and infected tissue, thus leaving a bone defect in its wake. Report of two cases: Two patients with periapical lesions were subjected to apicoectomy procedure where fibrin-rich plasma was placed as bone filling. Treatment was effective, since after 30 days a radio opaque area was radiographically observed, suggesting bone formation. Conclusion: Use of fibrin-rich plasma as bone filling after paraendodontic surgeries could represent a suitable alternative to commercial bone fillings, due to its bone induction properties.

Interdisciplinary management of an impacted dilacerated maxillary central incisor

ABSTRACT Introduction: Tooth dilacerations are dental anomalies characterized by an abrupt deviation in the longitudinal axis of a tooth. They may occur either in the crown, between the crown and root, or in the root. Although not so common, impacted maxillary incisors exhibiting root dilaceration pose a diagnostic and treatment challenge to the clinician. Description: This case report describes the management of a horizontally impacted and dilacerated maxillary central incisor in a 12-year-old girl. Cone-beam computed tomographic scans were used to accurately localize the position of the dilacerated tooth, and to assess the extent of root formation and degree of dilaceration present in the root. Treatment included surgical exposure and orthodontic traction, followed by root canal treatment and apicoectomy. Results: Through a meticulously planned interdisciplinary approach, the impacted dilacerated central incisor was properly aligned and demonstrated good stability after the long-term follow-up. Conclusion: Taking into consideration the concerns and expectations of the patient, communicative feedback between the oral surgeon, orthodontist and endodontist helped achieving successful esthetic, structural and functional outcome in the present case.

RESUMO Introdução: as dilacerações dentárias são anomalias caracterizadas por desvio acentuado no eixo longitudinal de um dente. Elas podem ocorrer na coroa, entre a coroa e a raiz, ou na raiz. Apesar de não serem muito comuns, os incisivos superiores impactados apresentando dilaceração radicular representam um desafio para o clínico, quanto ao diagnóstico e tratamento. Descrição: o presente relato de caso descreve o tratamento de um incisivo central superior impactado horizontalmente e com dilaceração, em uma menina com 12 anos de idade. Tomografias computadorizadas de feixe cônico foram utilizadas para localizar com precisão a posição do dente dilacerado e avaliar o grau de formação e de dilaceração da raiz. O tratamento incluiu exposição cirúrgica e tração ortodôntica, seguida de tratamento do canal radicular e apicectomia. Resultados: por meio de uma abordagem interdisciplinar meticulosamente planejada, o incisivo central impactado com dilaceração foi devidamente alinhado e demonstrou boa estabilidade em acompanhamento de longo prazo. Conclusão: levando-se em consideração as preocupações e expectativas da paciente, a comunicação interativa adotada entre o cirurgião oral, ortodontista e o endodontista ajudou na obtenção de resultados estéticos, estruturais e funcionais satisfatórios no presente caso.

Effects of four novel root-end filling materials on the viability of periodontal ligament fibroblasts

OBJECTIVES: The aim of this in vitro study was to evaluate the biocompatibility of newly proposed root-end filling materials, Biodentine, Micro-Mega mineral trioxide aggregate (MM-MTA), polymethylmethacrylate (PMMA) bone cement, and Smart Dentin Replacement (SDR), in comparison with contemporary root-end filling materials, intermediate restorative material (IRM), Dyract compomer, ProRoot MTA (PMTA), and Vitrebond, using human periodontal ligament (hPDL) fibroblasts. MATERIALS AND METHODS: Ten discs from each material were fabricated in sterile Teflon molds and 24-hour eluates were obtained from each root-end filling material in cell culture media after 1- or 3-day setting. hPDL fibroblasts were plated at a density of 5 × 103/well, and were incubated for 24 hours with 1:1, 1:2, 1:4, and 1:8 dilutions of eluates. Cell viability was evaluated by XTT assay. Data was statistically analysed. Apoptotic/necrotic activity of PDL cells exposed to material eluates was established by flow cytometry. RESULTS: The Vitrebond and IRM were significantly more cytotoxic than the other root-end filling materials (p < 0.05). Those cells exposed to the Biodentine and Dyract compomer eluates showed the highest survival rates (p < 0.05), while the PMTA, MM-MTA, SDR, and PMMA groups exhibited similar cell viabilities. Three-day samples were more cytotoxic than 1-day samples (p < 0.05). Eluates from the cements at 1:1 dilution were significantly more cytotoxic (p < 0.05). Vitrebond induced cell necrosis as indicated by flow cytometry. CONCLUSIONS: This in vitro study demonstrated that Biodentine and Compomer were more biocompatible than the other root-end filling materials. Vitrebond eluate caused necrotic cell death.

Dendritic cells and their relation to apical peridontitis

Abstract: The purpose of this manuscript was to re-discuss apical periodontitis, apical biofilm, and its possible relationship with dendritic cells (DC). DCs are potent regulators of the immune system and their function is divided into three categories that involve the presentation of antigens: the presentation of antigens and activation of T cells; a not well established category suggested that DCs induce and maintain immunological tolerance; and the maintenance of the immune memory in conjunction with B cells. DCs in periapical inflammatory lesions are composed of at least two subpopulations that can be distinguished on the basis of ultrastructure and phenotype. These populations might differ in lineage, state of maturation, differentiation, activation, and/or function. The authors hereby analyzed the root apexes of teeth under SEM, after performing apicoectomy due to the failure of conventional endodontic treatment. Microbial biofilm with multispecies and areas of resorption with the presence of Howship lacunae, and images suggestive of denditric cells could be observed. The presence of DCs in periapical lesion could be an indication of the severity of the lesion, with a constant presence of antigen in the periradicular region.

Paraendodontic surgery: case report / Cirurgia paraendodôntica: relato de caso

ABSTRACT Paraendodontic surgeries have been increasingly used to solve problems related to failures in conventional endodontic treatment. Better anatomical knowledge of the structures as well as the development of techniques and materials involved has resulted in substantial paraendodontic surgery increase and success. In some cases, teeth endodontic treatment highly benefits treatment accomplishment. This report describes a case of an endodontic treatment complemented by paraendodontic surgery in periapical region of 21, 22 and 23 of a female patient who had been treated at the clinic of the Brazilian Dental Association Dentistry - in the city of Cascavel, State of Parana, Brazil. The case presents a 12-month follow-up for the resolution of painful symptoms, lesion reduction, and bone formation. Literature review was performed regarding paraendodontic surgery in order to assess the determining factors, failure causes and procedure indications/contraindications, as well.

RESUMO A cirurgia paraendodôntica tem sido cada vez mais utilizada para sanar problemas inerentes aos insucessos no tratamento endodôntico convencional. O melhor conhecimento anatômico das estruturas envolvidas bem como a evolução das técnicas e dos materiais proporcionou um aumento significativo da utilização desta técnica e, por conseguinte seu maior sucesso. O tratamento endodôntico primário de um elemento dentário pode atingir altos índices de sucesso. Tornando-se, portanto, imprescindível para se atingir o sucesso do tratamento de alguns casos. Neste trabalho descreve-se um caso de tratamento endodôntico complementado por cirurgia paraendodôntica em região periapical dos elementos dentais 21, 22 e 23 de paciente do gênero feminino que foi tratada na Clínica de Odontologia da Associação Brasileira de Odontologia - Regional de Cascavel, Pr. O caso apresenta acompanhamento de 12 meses com resolução da sintomatologia dolorosa, redução da lesão e neoformação óssea. Foi realizada uma discussão com revisão da literatura sobre a cirurgia paraendodôntica avaliando os fatores determinantes, causas de insucessos, indicações e contraindicações do procedimento.