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.

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)

Alargamento do forame como complemento no tratamento endodôntico para regeneração de uma lesão periapical extensa: relato de caso / Foraminal enlargement as a complement in the endodontic treatment for the regeneration of an extensive periapical lesion. A case report

Introdução: O alargamento do forame refere-se ao alargamento mecânico intencional do forame para reduzir a carga bacteriana em uma área afetada frequentemente por infecções endodônticas além do limite da constrição apical. Objetivo: O objetivo do presente relato de caso é apresentar a técnica de alargamento do forame de um dente com lesão periapical extensa, como complemento do tratamento endodôntico e alternativa precoce à microcirurgia periapical. Métodos: É apresentado o caso de um incisivo lateral superior endodonticamente tratado, com uma extensa lesão periapical associada. Devido à história clínica e radiográfica, tempo decorrido desde o tratamento endodôntico inicial e alta probabilidade de áreas de reabsorção apical com biofilme extrarradicular, o retratamento endodôntico com alargamento do forame foi indicado como primeira opção, adiando a indicação de cirurgia endodôntica de acordo com a evolução. Resultados: Na avaliação de acompanhamento de dois anos, por exame de imagem, observou-se evolução clínica favorável ao retratamento, com aumento total da densidade óssea. O procedimento cirúrgico endodôntico complementar foi descartado. Conclusão: O alargamento do forame é uma alternativa complementar viável em casos de periodontite apical de longa duração com suspeita de biofilme no nível do forame. Pode ser considerado uma opção antes da indicação de retratamento endodôntico cirúrgico (AU).

Introduction: Foraminal enlargement refers to intentional mechanical enlargement of the foramen to reduce the bacterial load in an area frequently affected by endodontic infections beyond the limits of the apical constriction. The objective of this case report is to present the foraminal enlargement technique of a tooth with an extensive periapical lesion as a complement in the endodontic treatment and an early alternative to periapical microsurgery. Materials and methods: The case is presented of an endodontically treated upper lateral incisor with an extensive associated periapical lesion. Due to the clinical and radiographic history, the time elapsed since the initial endodontic treatment, and the high probability of areas of apical resorption with extra-radicular biofilm, endodontic retreatment with foraminal enlargement was indicated as the first option, postponing the indication for endodontic surgery according to evolution. Results: In the follow-up appointment at 2 years, a favorable clinical imaging evolution of retreatment was observed, with a total increase in bone density. The complementary endodontic surgical procedure was discarded. Conclusion: Foraminal enlargement is a viable complementary alternative in cases of long-term apical periodontitis with suspicion of biofilm at the foramen level. It can be considered an option before the indication of surgical endodontic retreatment (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)

Procedimento endodôntico regenerativo usando fibrina rica em plaquetas e leucócitos associada à cirurgia apical: relato de caso / Regenerative endodontic procedure using leukocyte- and platelet-rich fibrin associated with apical surgery: case report

ntrodução: A cirurgia parendodôntica é uma alternativa ao tratamento endodôntico convencional, principalmente em casos envolvendo lesões perirradiculares associadas a processos osteolíticos, em que a terapia endodôntica convencional ou seu retratamento não obtiveram sucesso. Novos métodos terapêuticos têm ganhado espaço na clínica odontológica para esse tipo de caso, entre os quais se destaca a fibrina rica em plaquetas e leucócitos, que, ao concentrar e permitir uma liberação mais prolongada dos fatores de crescimento, promove uma modulação do processo reparador. Esse processo é baseado na otimização da regeneração tecidual através da inserção da membrana de fibrina. Objetivo: O objetivo do presente trabalho é apresentar, por meio do relato de um caso clínico, a utilização de fibrina rica em plaquetas e leucócitos em cirurgia parendodôntica, com intuito de reparo ósseo. Resultados: O acompanhamento clínico e tomográfico foi realizado após 190 dias, momento no qual foi constatada ausência de sintomatologia, bem como completo reparo da lesão e restabelecimento do osso cortical vestibular, além de ausência de lesão detectável em tomografia. Conclusão: No caso clínico relatado, houve uma completa regeneração tecidual da área envolvida na lesão (AU).

Introduction: Parendodontic surgery is an alternative to conventional endodontic treatment, especially in cases involving periradicular lesions associated with osteolytic processes, in which conventional endodontic therapy or retreatment was not successful. New therapeutic methods for the treatment of these cases have ground in clinical dentistry . For example, leukocyteand platelet-rich fibrin which has a higher concentration and more prolonged release of growth factors, modulates the repair process. This process is based on the optimization of tissue regeneration through the insertion of fibrin membrane. Objective: The objective of this study is to report a case in which leukocyte- and platelet-rich fibrin associated with parendodontic surgery was used for bone repair. Results: Clinical and tomographic follow-up was performed after 72 days, which revealed absence of any symptoms, complete repair of the lesion, buccal cortical bone regeneration, and absence of detectable lesion on tomography. Conclusion: There was complete tissue regeneration at the lesion site(AU).

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)

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).

Endodontia guiada como alternativa para o tratamento de canais severamente calcificados / Guided endodontics as an alternative for the treatment of severely calcified canals

ntrodução: a calcificação pulpar é um dos fatores que tornam o tratamento endodôntico desafiador e capaz de comprometer o acesso dos instrumentos e soluções irrigadoras por toda extensão do canal radicular, impossibilitando sua adequada desinfecção. A Endodontia Guiada traz mais previsibilidade e segurança ao tratamento endodôntico nessa situação complexa. Métodos: uma vez constatada calcificação severa com necessidade de intervenção endodôntica, o paciente é encaminhado ao centro radiológico para o planejamento da Endodontia Guiada. Um modelo 3D da arcada a ser tratada é obtido por meio de um scanner de bancada e, posteriormente, transferido para um software de planejamento virtual de implante. A TCFC é adicionada a esse software e ambas são sobrepostas, com base em estruturas visíveis radiograficamente. O software Simplant é programado para projetar uma broca física, utilizada para o acesso endodôntico guiado, sobreposta virtualmente à calcificação do canal radicular. De posse da guia impressa, essa é posicionada na arcada do paciente e o procedimento clínico, executado. Conclusão: a técnica de Endodontia Guiada é rápida, previsível e clinicamente viável. Além disso, pode ser executada por profissionais menos experientes, não necessitando da utilização de microscópio operatório (AU).

Introduction: Pulp calcification is one of the factors that make endodontic treatment challenging and capable of compromising access of instruments and irrigant solutions to the entire extension of the root canal, making it impossible to disinfect it adequately. Guided endodontics makes the endodontic treatment more predictable and safer in this complex situation. Materials and Methods: Once severe calcification requiring endodontic intervention has been found, the patient is referred to the radiology center for the planning of guided endodontics. A 3D model of the arch to be treated is obtained by means of a bench scanner, afterwards transferred to a virtual implant planning software program. The CBCT is added to this software and both are superimposed on the basis of radiographically visible structures. The Simplant software is programmed to project a physical bur used for guided endodontic access, virtually superimposed on the root canal calcification. Once the printed guide has been obtained, it is positioned in the patient's arch and the clinical procedure is performed. Conclusion: The guided endodontic technique is easy, predictable and clinically feasible to perform. Moreover, it may be performed by less experienced professionals, and does not require the use of an operating microscope (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)

Clinical practice guidelines for the surgical endodontic management of post-treatment periapical disease / Guía de práctica clínica para el manejo quirúrgico en endodoncia de la enfermedad periapical postratamiento

ABSTRACT Introduction: in Colombia, persisting post-endodontic disease has been reported by up to 45%, validating the use of secondary alternative therapies, like endodontic microsurgery (EM). The aim of this study was to systematically-and with reliable scientific evidence-develop de Novo Clinical Practice Guidelines for the surgical endodontic management of post-treatment periapical disease (PPD), with more accurate recommendations for therapeutic decisions and preferences consulted with both practitioners and patients. Method: the guidelines developers team identified EM as a topic in the literature and established the scope, objective, questions, and outcomes, which were analyzed using the scientific evidence reported in secondary or primary clinical studies. A first screening identified titles and abstracts for each question asked. The validity of the selected studies was quantified with tools like AMSTAR or SIGN. Finally, the strength of recommendations and the quality of evidence were confirmed with GRADE. Results: concepts like PPD, EM indication, use of local anesthetics, antibiotics and presurgical anti-inflammatory drugs, effect of magnification, implementation of cone beam computed tomography, hemostasis, retrograde filling, and control time were integrated, supporting each topic with relevant evidence, experts' recommendations, and even good practice points. Conclusions: this document is considered a tool with sufficient evidence for clinical decision-making in EM.

RESUMEN Introducción: en Colombia, la persistencia de enfermedad posendodoncia ha sido reportada hasta en un 45%, lo cual justifica propuestas terapéuticas secundarias, como la microcirugía endodóntica (ME). El objetivo del presente estudio consistió en desarrollar sistemáticamente, y con evidencia científica confiable, una Guía de Práctica Clínica de Novo para el manejo quirúrgico en endodoncia de la enfermedad periapical postratamiento (EPP), con las recomendaciones más acertadas frente a decisiones y preferencias terapéuticas consultadas a profesionales y pacientes. Método: el grupo desarrollador de la guía identificó el tópico ME y estableció el alcance, el objetivo, las preguntas y los desenlaces, analizados mediante la evidencia científica registrada a partir de estudios clínicos secundarios o primarios. Un primer tamizaje identificó títulos y resúmenes para cada pregunta formulada. La validez de los estudios seleccionados se cuantificó con las herramientas AMSTAR o SIGN. Finalmente, la fuerza de las recomendaciones y la calidad de la evidencia se constataron con la herramienta GRADE. Resultados: se integraron los conceptos de EPP, indicación de la ME, uso de anestésicos locales, antibióticos y antinflamatorios prequirúrgicos, efecto de la magnificación, implementación de la tomografía computarizada de haz cónico, hemostasia, materiales de retroobturación y el tiempo de control, sustentando cada tópico con la evidencia, la recomendación de los expertos y en ocasiones con las premisas de las buenas prácticas. Conclusiones: el presente documento se considera una herramienta con suficiente evidencia para la toma de decisiones clínicas en ME.

O uso do microscópio operatório associado aos novos recursos na microcirurgia parendodôntica moderna / The use of the operating microscope associated with the new resources in modern endodontic microsurgery

Introdução: mesmo quando um tratamento endodôntico ou retratamento mais rigoroso é realizado, a periodontite apical pode persistir, levando à destruição do ligamento periodontal, cemento, osso alveolar e dentina. Nesses casos, o tratamento endodôntico cirúrgico, se realizado com o microscópio operatório (MO), ressecção mínima da raiz, retropreparo com pontas ultrassônicas e materiais para retrobturação biocompatíveis, pode alcançar mais de 90% de sucesso. Os procedimentos endodônticos cirúrgicos foram completamente transformados pela incorporação do MO, associado a novos recursos como aparelhos de ultrassom piezocirúrgico com pontas específicas para microcirurgia, microespelhos flexíveis, microexploradores, microcuretas endodônticas, microcondensadores e microinstrumentos para sutura. O MO pode otimizar todas as etapas de uma microcirurgia parendodôntica, incluindo o descolamento do retalho, a osteotomia, identificação do ápice radicular, apicectomia, remoção de tecido inflamatório, observação da superfície remanescente da raiz, retropreparo, obturação retrógrada e sutura. Objetivo: o objetivo do presente artigo é apresentar todos os passos da microcirurgia parendodôntica moderna e descrever os novos recursos disponíveis no mercado para melhorar a taxa de sucesso dessa modalidade. Conclusão: o uso de técnicas modernas de microcirurgia parendodôntica melhora significativamente as taxas de sucesso da terapia, quando comparada às técnicas tradicionais.

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.

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.

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.

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.

Computer aided design and three-dimensional printing for apicoectomy guide template / 北京大学学报(医学版)

OBJECTIVE@#To establish an apicoectomy guide template design and manufacturing method, based on multi-source data fusion, computer aided design (CAD) and fused deposition modeling (FDM). The feasibility of the guide template was preliminary evaluated by the in vitro model experiment.@*METHODS@#An extracted upper anterior tooth, after root canal treatment, was optical scanned, after which the extracted upper anterior tooth was poured in an apicoectomy plaster model. Cone-beam computed tomography (CBCT) scanning of the apicoectomy plaster model was performed, after which optical scanning of the plaster model for apical resection surgery was carried out. All of the relevant CBCT and optical scanning data of the extracted upper anterior tooth and the apicoectomy plaster model were introduced into the Geomagic Studio 2012 software. The multi-source data fusion technology was used to virtually simulate the three-dimensional positional relationship of the extracted tooth, the dentition, the alveolar bone and the gingival, based on which, the three-dimensional design of the apicoectomy guide template was completed in the Geomagic Studio 2012 software. With the technology of fused deposition modeling, the apical resection surgical guide template was three-dimensionally printed with the material of polylactic acid (PLA). Under the guidance of the surgical guide template, the root apical resection was performed on the plaster model. After the apicoectomy, the extracted upper anterior tooth was taken off from the apicoectomy plaster model and then was given the optical scanning. The apical resection length and angle were calculated by the function of distance measurement and angle measurement, and the results were compared with the preset values.@*RESULTS@#The length of the apical resection was 2.88 mm along the direction of the long axis of the tooth, which was 0.12 mm lower than the preset 3 mm. The included angle between the apical resection plane and the long axis of the tooth was 77.9°, 12.1° lower than the preset 90°.@*CONCLUSION@#This study successfully established a digital design and production method of apicoectomy guide template by combing the multi-source data fusion, CAD and FDM technology. The design route and the production method are feasible. The study will provide a technology and methodology reference for the development of domestic special software for the digital design of apicoectomy guide template.

Análise comparativa da adaptação marginal, infiltração microbiana e da citotoxicidade em ápices retrobturados com os cimentos Palacos-R e MTA / Comparative analysis of marginal adaptation, microbial leakage and cytotoxicity in apices in retrofills with cements Palacos-R and MTA

O sucesso do tratamento endodôntico está relacionado com uma adequada limpeza, modelagem e um bom selamento do sistema de canais radiculares. A cirurgia parendodôntica é um procedimento que tem como finalidade resolver problemas que não puderam ser solucionados pelo tratamento endodôntico convencional nem pelo retratamento. Essas cirurgias são realizadas através da exposição e remoção dos ápices radiculares, confecção de retrocavitações no longo eixo dos canais radiculares e retrobturações com materiais seladores específicos. Sendo assim, o presente trabalho teve o objetivo de realizar um estudo comparativo dos cimentos MTA (Agregado Trióxido Mineral) e Palacos-R (cimento ósseo) nas retrobturações endodônticas através da avaliação da adaptação marginal, da infiltração microbiana e da citotoxicidade. Para avaliação da adaptação marginal e da capacidade seladora pelo método da infiltração microbiana, foram selecionados 48 caninos superiores permanentes humanos extraídos, instrumentados e obturados. As apicetomias para a remoção dos 3mm apicais das raízes foram realizadas com a utilização da ponta ultrassônica diamantada CVD DENTUS 8.1117. Os retropreparos foram confeccionados com pontas ultrassônicas diamantadas CVD DENTUS 6.1107-E, com 4mm de profundidade. As 28 amostras foram retrobturadas com o cimento ósseo Palacos-R (HERAEUS KULZER) e o cimento MTA cinza (ANGELUS), num total de 14 espécimes para cada cimento testado. A avaliação da adaptação marginal foi realizada pela microscopia eletrônica de varredura (MEV) com 8 dentes (4 para cada cimento retrobturador). A capacidade seladora foi analisada através de ensaios de infiltração bacteriana com Enterococcus faecalis (ATCC 29212), com 10 dentes para o grupo do Palacos-R, 10 dentes para o grupo do MTA cinza, 10 dentes para o grupo controle positivo e 10 dentes para o grupo controle negativo. A avaliação da citotoxicidade foi feita com os eluatos dos cimentos pelo teste MTT, com fibroblastos gengivais de camundongos (células L929). A análise ao MEV mostrou uma melhor adaptação do Palacos-R aos retropreparos do que o MTA cinza. Apesar do Palacos-R ter obtido os menores índices numéricos de infiltração bacteriana, não houve diferença estatisticamente significativa entre ambos. Os dois cimentos não demonstraram atividade citotóxica sobre células L929, contudo nos extratos duplamente concentrados o cimento Palacos-R foi menos citotóxico do que o MTA cinza (P< 0.0001). Pôde-se concluir que o Palacos-R apresentou uma melhor adaptação marginal do que o MTA cinza ao MEV, que não houve diferença entre o Palacos-R e o MTA quanto à infiltracao microbiana e a citotoxicidade tornando-o um material retrobturador promissor a ser utilizado em Endodontia

The success of endodontic treatment is related to a proper cleaning, and a good seal of root canal system. Paraendodôntic surgery is a procedure that aims to solve problems that couldn't be solved by conventional endodontic treatment. These surgeries are performed by exposing and removing the root tips, making retrocavitations on the long axis of the root canals, and retrofilling with specific sealant materials Thus, the present work had the objective of performing a comparative study of MTA (Mineral Trioxide Aggregate) and Palacos-R (bone cement) cements in endodontic retrofillings through the evaluation of marginal adaptation, microbial infiltration and cytotoxicity. To evaluate the marginal adaptation and the sealing ability by the microbial infiltration method, 48 human permanent upper canines were selected, instrumented and obturated. The apicetomies for removal of the apical 3mm from the roots were performed using the diamond ultrasound tip CVD DENTUS 8.1117. The retroprepares were made with ultrasonic CVD DENTUS 6.1107-E diamond tips, 4mm deep. The 28 samples were retrobured with the Palacos-R (HERAEUS KULZER) cement and the gray MTA cement (ANGELUS), in a total of 14 specimens for each cement tested. The evaluation of the marginal adaptation was performed by scanning electron microscopy (SEM) with 8 teeth (4 for each retroburst cement). Sealing capacity was analyzed through bacterial infiltration assays with Enterococcus faecalis (ATCC 29212), with 10 teeth for the Palacos-R group, 10 teeth for the gray MTA group, 10 teeth for the positive control group and 10 teeth for the the negative control group. Cytotoxicity evaluation was performed with the eluates of the cements by the MTT test, with mouse gingival fibroblasts (L929 cells). The SEM analysis showed a better adaptation of the Palacos-R to the retroprepares than the gray MTA. Although Palacos-R had the lowest numerical rates of bacterial infiltration, there was no statistically significant difference between the two. The two cements did not demonstrate cytotoxic activity on L929 cells, however in the doubly concentrated extracts the Palacos-R cement was less cytotoxic than the gray MTA (P <0.0001). It was concluded that the Palacos-R presented a better marginal adaptation than the gray MTA to the SEM, that there was no difference between the Palacos-R and the MTA in terms of microbial infiltration and cytotoxicity, making it a promising retrofilling material to be used in Endodontics