Endodontic apical surgery with novel endoscope: Three-case series.

Successful apical surgery relies on effective magnification and illumination. In the field of endodontics, the microscope has emerged as the predominant tool for meeting these requirements. The rigid endoscope is also a valuable instrument in apical surgery. This study introduces three cases demonstrating the application of endoscope technology in endodontic apical surgery. The first case employs a soft endoscope for treating an anterior tooth with apical periodontitis, the second integrates an endoscope with new attachments for a premolar, and the third combines an endoscope, attachments and navigation for the lower first molar surgery. It revealed that endoscopes offer certain advantages that are not achievable with microscope-assisted surgery, these cases had a great outcome. In the future, a broader application of endoscopic technology in various procedures is anticipated.

Comparative Analysis of Examination Methods for Periapical Lesion Diagnostics: Assessing Cone-Beam Computer Tomography, Ultrasound, and Periapical Radiography.

INTRODUCTION: Periapical lesions of teeth are typically evaluated using periapical X-rays (PA) or cone-beam computer tomography (CBCT); however, ultrasound imaging (US) can also be used to detect bone defects. A comparative analysis is necessary to establish the diagnostic accuracy of US for the detection of periapical lesions in comparison with PA and CBCT. OBJECTIVES: This study aimed to evaluate and compare the measurement precision of US against PA and CBCT in detecting periapical lesions. METHODS: This study included 43 maxillary and mandibular teeth with periapical lesions. All teeth were examined clinically, radiographically, and ultrasonographically. Observers evaluated and measured the periapical lesions on CBCT, PA, and US images. RESULTS: The comparison of lesion size showed that it differs significantly between the different methods of examination. A statistically significant difference was found between CBCT and US (mean difference = 0.99 mm, 95% CI [0.43-1.55]), as well as between CBCT and PA (mean difference = 0.61 mm, 95% CI [0.17-1.05]). No difference was found between the US and PA methods (p = 0.193). CONCLUSION: US cannot replace PA radiography in detecting pathologies but it can accurately measure and characterize periapical lesions with minimal radiation exposure. CBCT is the most precise and radiation-intensive method so it should only be used for complex cases.

The use of guided tissue regeneration in endodontic Microsurgery: Setting a threshold.

Aim: We aimed to compare the radiographic outcomes of conventional and regenerative approaches in endodontic microsurgery (EMS) and set a critical defect size for healing in conventional and regenerative therapies. Methodology: The study evaluated 53 root canal-treated teeth (33 patients) with periapical lesions. Among them, 19 teeth (35.8 %) were treated with regenerative treatment, whereas 34 teeth (64.1 %) were managed with the conventional approach. Conventional and regenerative approaches were performed by endodontic and periodontic residents under consultants' supervision. Healing was evaluated after a minimum period of 6 months by comparing pre- and post-operative cone-beam computed tomography (CBCT) findings. The radiographic interpretation was conducted by a single examiner who was not participating in the surgeries and was blind on the type of treatment prior to CBCT evaluation. New healing criteria were proposed owing to the limitations on the present criteria in evaluating endodontic surgery after regenerative treatment. Critical measurements were calculated for each approach based on periapical lesion dimensions. Results: The regenerative approach presented significantly better healing than conventional treatment (mean, 1.21 and 1.59, respectively; p = 0.047). Based on the critical-point calculations, the conventional approach was effective in lesions of up to 3 mm depth and height, whereas the regenerative approach resulted in better healing rates in lesions with 3-9 mm depth and 3-6 mm height. Conclusions: Performing the regenerative approach in EMS resulted in better healing rates than those of the conventional approach. The conventional approach is recommended for small periapical lesions, whereas the first had better results in larger lesions.

The applications of the plasma matrix in the treatments of dental pulp and periapical diseases / 口腔疾病防治

@#The plasma matrix is a kind of autologous blood conduct. It has been widely used in maxillofacial tissue regeneration, skin cosmetology and some other fields. Recently, to preserve the dental pulp as well as the teeth, pulp regeneration therapy and apical surgery have become increasingly important as well as the applications of bioactive materials. As a kind of autologous bioactive material, the plasma matrix has some natural advantages as it is easy to obtain and malleable. The plasma matrix can be used in the following cases: ①pulp revascularization of young permanent teeth with open apical foramina that cannot stimulate apical bleeding; ② apical barrier surgery with bone defects and large area perforation repair with bone defects or root sidewall repair surgery; ③ apical surgeries of teeth with large area of apical lesions, with or without periodontal diseases. The plasma matrix is a product derived from our blood, and there are no obvious contraindications for its use. Several systematic reviews have shown that the plasma matrix can effectively promote the regenerative repair of dental pulp in patients with periapical diseases. However, the applications of plasma matrix are different because its characteristics are affected by different preparation methods. In addition, there is still a lack of long-term clinical researches on the plasma matrix, and the histological evidences are difficult to obtain, so a large number of in vitro and in vivo experimental studies are still needed. This article will describe the applications of different kinds of plasma matrix for dental pulp regeneration and bone tissue regeneration in apical surgeries to provide references for clinicians in indication selection and prognosis evaluation.

Interfacial adaptation of NeoMTA Plus, BioRoot RCS and MTA in root-end cavities: A micro-CT study.

AIM: This study aimed to use the micro-computed tomography to evaluate the interfacial adaptation and the presence of gaps of NeoMTA Plus, BioRoot RCS, and MTA in the root-end cavities. METHODOLOGY: Thirty standardized bovine roots measuring 15 mm in length were selected. Chemical-mechanical preparation was performed up to instrument #80 and obturation with the cold lateral compaction technique with cement based on zinc oxide and eugenol. The roots were kept at 37°C for 7 days. Afterward, apicectomy of the apical 3 mm and a root-end filling cavity was performed at 3 mm depth. Micro-computed tomography (micro-CT) was performed to measure the volume of the retroactivity. The roots were divided by stratified randomization into three groups according to the retro-end filling material: NeoMTA Plus, BioRoot RCS, and MTA. A new micro-CT was performed to assess the presence of voids in the root-end filling material and between it and the canal wall. One-way ANOVA and Tukey tests were performed using the BioEstat 4.0 program. RESULTS: There was no difference in the initial volume values of the root-end cavities (p > .05). After the insertion of root-end filling materials, the most significant volumes of voids were observed in the NeoMTA Plus group (p < .05), with no difference for the BioRoot RCS and MTA Angelus groups (p > .05). CONCLUSION: Micro-computed tomography showed that MTA and BioRoot RCS have better interfacial adaptation and presented fewer number of gaps than NeoMTA Plus when used as root-end filling materials. RESEARCH HIGHLIGHTS: Micro-computed tomography evaluation of different root-end fillings materials.

Assessment of Quality and Readability of Online Patient-Centered Arabic Web-Based Knowledge About Apicoectomy.

Background Endodontic microsurgery (apicectomy) can be considered in cases of persistent infection that is resistant to conventional root canal treatment. The aim of this study was to evaluate the quality and readability of the available online information regarding the apicectomy procedure in Arabic. Methods Online search on the three most commonly used websites (Google, Yahoo, and Bing) using one keyword. The first 100 websites from each search were analyzed for quality and readability using DISCERN instrument scores, the Journal of the American Medical Association (JAMA) benchmarks, the Health On the Net (HON) seal, Flesch Reading Ease Scores (FRES), Flesch-Kincaid Grade Level (FKGL), and the Simplified Measure of Gobbledygook (SMOG) Index. Results Searching using the Arabic translation for "root end resection surgery" revealed 349,900 websites. Following the inclusion criteria, 31 websites were selected and evaluated in this study. The selected websites belonged to either non-profit organizations or commercial websites. The quality of most of the selected websites received a moderate score (83.9%) using the DISCERN tool. None of the selected websites obtained the HON seal. Quality evaluation using the JAMA benchmarks revealed that currency was the most achieved item (45.2%), followed by authorship (22.6%). Evaluation of the readability of the selected websites using the FRES, FKGL, and SMOG showed that the included websites were considered readable. Conclusion Although the included websites were readable, the quality of the websites was moderate. There is an urgent need to create more trustworthy and readable websites explaining the different endodontic treatments.

The management of gingival fenestration: A series of three cases.

OBJECTIVES: The aim of this article is to introduce three treatments for patients with gingival fenestration as a result of chronic apical periodontitis. Gingival fenestration is a relatively uncommon soft tissue lesion in which the root apex is exposed in the oral environment after the destruction of the overlying buccal bone plate and mucosa. At present, no clear etiology or treatment guidelines exist for gingival fenestration. This article reports three successfully treated cases of gingival fenestration associated with chronic periapical infection. This report can help contribute to treatment guidelines for gingival fenestration. METHODS: All cases were treated with apicoectomy in conjunction with a connective tissue graft (CTG). According to the different conditions of the patients, we used some slightly different treatment methods during the operation. In case 1, we treated gingival fenestration in the mandibular left first premolar by endodontic therapy with root-end resection and retrograde filling and regenerative surgical therapy using a xenograft and CTG. In case 2, we treated gingival fenestration in the maxillary left lateral incisor by endodontic therapy with root-end resection and retrograde filling in vitro and regenerative surgical therapy using advanced platelet-rich fibrin (A-PRF) and CTG. In case 3, we treated gingival fenestration in the mandibular left second premolar by endodontic therapy with root-end resection and retrograde filling and regenerative surgical therapy using CTG. RESULTS: Endodontic treatment was combined with periodontal surgery to achieve predictable treatment results. After 13 to 25 months of follow-up, all cases showed that the gingival fenestration had healed well, and the patients had no discomfort. CONCLUSIONS: These three cases show the possibility of using apical excision combined with a CTG and/or bone graft/PRF in the treatment of gingival fenestration. Reporting these three cases may help advance the field of treatments for gingival fenestration.

Application of Real-time Augmented Reality-guided Osteotomy and Apex Location in Endodontic Microsurgery: A Surgical Simulation Study Based on 3D-printed Alveolar Bone Model.

INTRODUCTION: Augmented reality (AR) is a novel visualization technique in which pregenerated virtual 3D content is superimposed on surgical sites. This study aimed to validate the viability of AR-guided endodontic microsurgery (ARG) and compare the changes in objective and subjective outcomes of surgical simulation using ARG and freehand (FH) endodontic microsurgery on customized 3D-printed models. METHODS: We created and printed a customized 3D alveolar bone model with artificial periapical lesions (APLs) based on cone-beam computed tomography. Eight models with 96 APLs were equally divided into ARG and FH groups. We planned surgical trajectories on rescanned printed models. Four inexperienced residents (IRs) performed ARG and FH on the models and completed pre and intraoperative confidence questionnaires for the subjective outcome. Postoperative cone-beam computed tomography scans of the models were reconstructed and analyzed, and all procedures were timed. We used pairwise Wilcoxon rank sum tests to compare objective outcomes. Kruskal-Wallis tests and post hoc pairwise Wilcoxon rank sum tests were used to compare subjective outcomes. RESULTS: Compared to the FH group, the ARG group significantly reduced deviation of the volume of bone removal, root-end resection, and deviation of bevel angle, with improved confidence of the IRs (P < .05); it also significantly increased surgical time and volume of unremoved APL (P < .05). CONCLUSIONS: We customized an APL model through 3D printing and developed and validated a low-cost AR application framework, based on free AR software, for endodontic microsurgery. ARG allowed IRs to perform more conservative and precise surgical procedures with enhanced confidence.

Combined micro-apical surgery and vital pulp therapy in mandibular second molars with external root resorption caused by impacted teeth.

OBJECTIVES: This study aimed to establish a new treatment of the mandibular second molars with external root resorption caused by impacted teeth to preserve the affected teeth and their vital pulps. METHODS: For mandibular second molars clinically diagnosed as external root resorption caused by impacted teeth, debridement and removal of the root at the resorption site via micro-apical surgery and direct capping of the pulp with bioactive material on the surface of the root amputation via vital pulp therapy were performed immediately after the impacted teeth were extracted. RESULTS: The external root resorption of the affected tooth was ceased. It was asymptomatic with intact crown, normal pulp, periapical alveolar bone reconstruction, normal periodontal ligament, continuous bone sclerosis, and no periapical translucency in radiographic examination at the 1-year postoperative follow-up, thus showing good prognosis. CONCLUSIONS: Simultaneous combination of micro-apical surgery and vital pulp therapy after extraction of impacted teeth could successfully preserve mandibular second molars with ERR caused by impacted teeth and their vital pulps.

Comparison of a Novel Static Computer-aided Surgical and Freehand Techniques for Osteotomy and Root-end Resection.

INTRODUCTION: This study compared the accuracy and efficiency of a novel static computer-aided surgical technique using a 3-dimensional (3D)-printed surgical guide (3D-SG) with a fully guided drill protocol (3D-SG FG) to the freehand (FH) osteotomy and root-end resection (RER). METHODS: Forty-six roots from 2 cadaver heads were divided into 2 groups: 3D-SG FG (n = 23) and FH (n = 23). Cone-beam computed tomographic scans were taken preoperatively and postoperatively. The endodontic microsurgery was planned in Blue Sky Bio software, and the 3D-SG was designed and 3D printed. The osteotomy and RER were conducted using a guided twist drill diameter of 2 mm and an ascending tapered drill with diameters of 2.8/3.2, 3.2/3.6, 3.8/4.2, and 4.2 mm with respective guided drill guides. Two-dimensional and three-dimensional virtual deviations and angular deflection were calculated. Linear osteotomy measures and root resection angle were obtained. The osteotomy and RER time and the number of mishaps were recorded. RESULTS: Two-dimensional and three-dimensional accuracy deviations and angular deflection were lower in the 3D-SG FG protocol than in the FH technique (P < .05). The height, length, and depth of the osteotomy and root resection angle were less in the 3D-SG FG protocol than in the FH technique (P < .05). The osteotomy and RER time with the 3D-SG FG protocol were less than the FH method (P < .05). CONCLUSIONS: Within the limitations of this cadaver-based study using denuded maxillary and mandibular jaws, 3D-SG FG protocol showed higher accuracy than FH osteotomy and RER. Moreover, the 3D-SG FG drill protocol significantly reduced the surgical time.

Non-surgical root canal treatment and retreatment versus apical surgery in treating apical periodontitis: A systematic review.

BACKGROUND: In addition to non-surgical root canal treatment or retreatment, apical surgery may be carried out to manage teeth with apical periodontitis. However, it is unclear which treatment option is more effective. OBJECTIVE: To systematically review the effectiveness of apical surgery compared with non-surgical treatment or retreatment in terms of clinical and patient-related outcomes in teeth with apical periodontitis. METHODS: A literature search of electronic databases, the grey literature, the reference lists of included articles and previous reviews, and a hand search of leading endodontic journals, was conducted. Randomised and non-randomised control trials, and longitudinal observational studies on patients undergoing surgical (treatment group) and non-surgical root canal treatment or retreatment (control group) of teeth with apical periodontitis were included. The risk of bias was appraised using the Cochrane risk-of-bias tool; ROBINS-I and the Newcastle-Ottawa Scale. RESULTS: Five studies, consisting of two randomised clinical trials, two non-randomised clinical trials, and a retrospective cohort study, were included. The interobserver agreement was high and kappa correlation coefficient was good. In total 529 teeth were available for follow-up that varied from 6 months to 8.7 years. The overall risk of bias was high for four studies and raised some concerns in one study. Apical surgery showed seemly better results regarding periapical healing and less need for more and further intervention, although tooth survival was higher in the control group. Given the heterogeneity of the studies, meta-analysis was not possible. DISCUSSION: Previous systematic reviews have conducted an indirect comparison by separately pooling the outcomes of studies analysing either non-surgical, or surgical, treatment. In this systematic review, only studies that compared both treatments were included. Most results of this and previous reviews were similar. CONCLUSION: No treatment option showed clear superiority. However, to arrive at statistically supported conclusions there is a need for additional high-quality comparative trials. REGISTRATION: PROSPERO database (Registration number CRD42021260300).

Combined micro-apical surgery and vital pulp therapy in mandibular second molars with external root resorption caused by impacted teeth / 华西口腔医学杂志

OBJECTIVES@#This study aimed to establish a new treatment of the mandibular second molars with external root resorption caused by impacted teeth to preserve the affected teeth and their vital pulps.@*METHODS@#For mandibular second molars clinically diagnosed as external root resorption caused by impacted teeth, debridement and removal of the root at the resorption site via micro-apical surgery and direct capping of the pulp with bioactive material on the surface of the root amputation via vital pulp therapy were performed immediately after the impacted teeth were extracted.@*RESULTS@#The external root resorption of the affected tooth was ceased. It was asymptomatic with intact crown, normal pulp, periapical alveolar bone reconstruction, normal periodontal ligament, continuous bone sclerosis, and no periapical translucency in radiographic examination at the 1-year postoperative follow-up, thus showing good prognosis.@*CONCLUSIONS@#Simultaneous combination of micro-apical surgery and vital pulp therapy after extraction of impacted teeth could successfully preserve mandibular second molars with ERR caused by impacted teeth and their vital pulps.

Addition of MTA in a salicylate-based resin root canal sealer to retrograde root-end filling

Aim To evaluate the flow, pH and calcium release of white MTA (WMTA), salicylate-based resin root canal sealer (Sealapex; SEAL) and SEAL containing 10 (SE10) or 20% (SE20) (w/w) of MTA. Methodology Flow test was realized according to ISO 6876 specification. The sealers samples (n= 10) were placed in polyethylene tubes and immersed in deionized water. After 24 hours and 7, 14, and 28 days, the water pH was determined with a pH meter, and calcium release was assessed by atomic absorption spectrophotometry. Results SEAL and WMTA showed respectively the highest and lowest flow rate when compared with the other materials (P<0.05). SE20 showed the highest pH value only in 24h and 7 days periods (p<0.05). In 14- and 28-days periods, SEAL showed the lowest pH value (p<0.05), but there are no differences between other groups (p>0.05). In all periods, WMTA and SEAL respectively showed the highest and lowest calcium release (p<0.05). Conclusions SE20 proves to be an association with better flow and handling than WMTA, with satisfactory potential for alkalinization and calcium release.

Dislodgement pushout resistance of five bioceramic root-end filling materials.

This study evaluated the dislodgement push-out resistance of five bioceramic materials. One hundred single-rooted teeth with one canal had the apical 3 mm and crown resected to create a 14 mm standardized length. The canals were instrumented to an apical size 80 with a 3 mm root-end preparation made with ultrasonic diamonds. The prepared roots were randomly divided into 5 root-end restorative groups (n=20). ProRoot MTA, Biodentine, EndoSequence Root Repair Material, EndoSequence Fast Set Putty, and EndoSequence BC Sealer with each material placed following manufacturer's instructions and stored at 100% humidity for 2 weeks. An apical-to-coronal static testing load with the identified dislodgement force converted into MPa with mean results analyzed with Kruskal-Wallis and Dunn's post hoc tests (α=0.05). ProRoot MTA and Biodentine displayed similar push-out stress resistance and exhibited significantly greater stress resistance than the similar Endosequence materials. However, all materials failed cohesively and were not dislodged from the root canal surface.

Effect of apical microsurgery on force regulation of incisor teeth during unpredictable force control task.

BACKGROUND: Apical microsurgery (AMS) involves removal of the root-end which can affect the force regulation of teeth. OBJECTIVE: To investigate the force regulation of incisor teeth treated with AMS during the unpredictable force control task in comparison with their contralateral teeth with complete root apices, in humans. METHODS: Fifteen eligible participants (8 women and 7 men; mean age 52.9 ± SD 4.4 years) performed a standardised unpredictable force control task, which involved pulling and holding a force transducer with AMS-treated incisors and their contralateral control teeth (n = 30 teeth). A series of four load masses: 100, 200, 50 and 300 gm were attached to the force transducer through a string in an unpredictable manner. The obtained force profile was divided into initial and later time-segments. The peak force and peak force rate during the initial time-segment, and the holding force and coefficient of variability during the later time-segments were calculated and compared by the repeated measures analysis of variance. RESULTS: During the initial time-segment, the peak force and peak force rate were significantly lower in the AMS-treated teeth than in the controls (p = .001, p = .013, respectively). However, during the later time-segment, no significant differences in the holding force nor the coefficient of variability were observed between the AMS-treated teeth and their controls (p = .755, p = .213, respectively). CONCLUSION: In contrast to incisors with complete normal root apices, AMS-treated incisors do not show robust changes in force regulation.

Psycho-social perspectives of nonsurgical versus surgical endodontic interventions in persistent endodontic disease.

INTRODUCTION: Patients' experiences related to dental treatment could influence care-seeking behaviour and engender personal bias. Although endodontic retreatment and apical surgery are procedures often performed to manage previously treated teeth with persistent disease, there is lack of information regarding psycho-social perspectives of patients who undergo these treatments. Our aim was to compare experiences of patients who received these two treatment modalities using a qualitative approach. METHODS: A purposive sample of patients was taken from our previous study utilizing the Oral Health Impact Profile to compare oral health-related quality of life of 150 patients who received retreatment and apical surgery. Patients who reported impact and no impact were invited to participate in focus group discussions (FGDs). Eighteen patients from the retreatment group and 15 patients from the surgical group participated in six FGDs. Thematic analysis was conducted to identify key themes. RESULTS: Four themes emerged: (1) psycho-social disability associated with dental procedures, (2) physical disability associated with dental problems, (3) reliance on dentist's advice for treatment and (4) self-management to preserve treated teeth. Patients undergoing endodontic retreatment reported significant time loss from work and were less informed of alternative treatment options. However, they were pleased with the aesthetics of their teeth, especially if new crowns were made. Patients undergoing surgery experienced anxiety related to loss of control during surgery and apprehension on visualizing the wound post-surgery. They reported more impact on their diet, social interaction and sleep quality and some felt self-conscious due to post-treatment gingival recession. Patients in both groups placed great trust in professional advice and expressed a clear desire to maintain their natural dentition. There was low awareness regarding long-term care and future sequelae of their treated tooth. CONCLUSIONS: Patients reported different psycho-social and physical impacts following endodontic retreatment and apical surgery. Patients undergoing endodontic retreatment were more satisfied with aesthetic outcomes but experienced greater impact related to complexities and length of time taken for treatment. Patients undergoing surgery were better informed of treatment options but experienced greater physical and psycho-social disability during the recovery phase. Clinicians could consider incorporating findings from this study into the patient-dentist discussion.

3D printing in endodontics: report of three clinical cases with innovative approaches.

3D printing is a process whereby a given material is deposited in successive layers to create a 3D object. In dentistry, this technology involves three steps: digital data acquisition using a scanner and/or CBCT, data processing and design within a software application, and manufacturing through 3D printing. The aim of the present article is to discuss the clinical application of 3D printing in endodontics through the presentation of three specific and original endodontic clinical cases. Innovative approaches were utilized in these cases for the treatment of a calcified root canal, periapical surgery, and autotransplantation. The results of all three cases were promising regarding proper case selection and in the design process. 3D-printing technology may be helpful to reduce surgical time, operator bias, and the risk of procedural errors.

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

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