Objective: To report the endodontic retreatment of tooth 26 with an extensive periapical lesion, assessing the clinical and radiographic evolution. Case report: A 36-year-old male patient, with a history of endodontic treatment of tooth 26 performed approximately six years earlier, presented discomfort in the maxillary molar region. Radiographic and cone-beam computed tomography (CBCT) examinations revealed an extensive periapical lesion and the presence of a second untreated mesiobuccal canal (MB2). Retreatment was performed on the palatal (P), distobuccal (DB), and mesiobuccal (MB) canals, in addition to treatment of MB2, using calcium hydroxide–based intracanal medication and obturation by the lateral condensation technique. During follow-up, evidence of complete lesion regression and bone repair was observed. Conclusions: Endodontic retreatment with the technique used proved effective in promoting regression of the extensive periapical lesion, representing a conservative alternative to periradicular surgery. The high capability of CBCT in elucidating situations involving complex anatomical variations was also evident, highlighting its relevance as a valuable tool in the management of such cases.

Effect of allograft and collagen membrane application on periapical and labial bone regeneration in apicomarginal defects treated with endodontic microsurgery: a randomized controlled trial.

Teeth exhibiting internal root resorption or those with persistent large periapical lesions after non-surgical endodontic treatment are generally considered to have an unfavorable prognosis. Extraction of teeth with unfavorable prognosis, followed by dental implant placement, has become an acceptable treatment option. However, dental implants are not indicated for young people with growing jaws. Consequently, it is recommended that clinicians prioritize the preservation of natural dentition in younger patients and defer implant therapy until skeletal growth has ceased. In cases where tooth preservation is attempted despite severe periradicular defects, a surgical approach is often required to manage associated symptoms. However, modern periradicular surgery frequently leads to unaesthetic complications such as conspicuous scar formation or gingival recession. The introduction of novel combinatory surgery, including guided tissue regeneration (GTR), de epithelialized free gingival graft (DFGG), and coronally advanced flap (CAF) optimizes the clinical outcomes, addressing both the functional and aesthetic needs of the patient.

Abstract Endodontic therapy usually achieves high success rates, yet persistent large periapical lesions may require surgical management. This report presents two cases of radicular cysts with cortical perforations treated surgically after failed nonsurgical root canal treatment. In the first case, a 55-year-old woman exhibited a large mandibular anterior lesion causing swelling and tenderness, while the second involved a 40-year-old woman with a palatal lesion extending across the midline. Both cases underwent chemo-mechanical root canal preparation, intracanal medicaments, and obturation using mineral trioxide aggregate (MTA). Persistent symptoms prompted periradicular surgery with apicoectomy, cyst enucleation, and adjunctive use of platelet-rich fibrin (PRF) to promote healing. Follow-up CBCT showed satisfactory bone regeneration and symptom resolution after 10 to 12 months. These cases underscore the importance of surgical intervention combined with regenerative materials for managing large, complex periapical lesions when nonsurgical approaches fail. PRF and MTA enhance biological healing and improve clinical outcomes in endodontic microsurgery.

Purpose: The aim of the study is to observe the bone healing process of a guided periradicular surgery, performed in the endodontics postgraduate course of the University of Santo Tomas, in which an osteotomy was performed for a bone window with erbium, chromium: yttrium, scandium, gallium, garnet (Erbium,Chromium:YSGG) laser, and the healing process was evaluated by cone beam computed tomography (CBCT) during the first four months after surgery. Materials and Methods: After completing the clinical history and studying the CBCT scans, a patient was selected with a diagnosis of symptomatic apical periodontitis, periapical lesion less than 5mm with intact vestibular cortex that required periradicular surgery due to the presence of an adapted fixed prosthesis and the proximity of the mental foramen to the apex of the tooth to be treated. The treatment plan was established, the surgical guide was designed and the osteotomy was performed with Erbium,Chromium:YSGG laser. The size of the periradicular lesion and the bone density of the surgical area were measured at three points in time: pre-surgical (T0) and post-surgical at 24 hours (T1), at 4 months (T2) and at one year. Results: Bone density measured in Hounsfield units (HU) on CBCT in the axial section showed preoperative values in the vestibular apex of 1478 and 1435 HU, at 24 hours after surgery -95 and -210 HU, and in the control at 4 months of 992 and 860 HU. In the coronal slice in the mid vestibular area at the apex level, a preoperative value (T0) of 1335 HU was reported, at 24 hours (T1) -18 HU and at 4 months 1269 HU. At one year of evolution, greater bone density was evidenced comparing between month 4 and month 12. Conclusions: By performing a surgical procedure with guided technique and Erbium,Chromium:YSGG laser for the osteotomy, the adverse effects of the surgical procedures are reduced, achieving results with greater accuracy and better prognosis.

In the root canal system, infection of the pulp tissue caused by caries or other pathways is the primary cause of apical periodontitis. The ultimate goal of the endodontic treatment is to create adequate conditions for periradicular tissue healing. Nonsurgical endodontic treatment is a highly predictable treatment option in most cases, but surgery may be indicated for teeth with persistent periradicular pathosis unresponsive to nonsurgical approaches. The aim of this article is to highlight the possibility of the successful outcome of surgical endodontic treatment following failed non-surgical treatment of right maxillary central incisor. With proper case selection and operator skill, periradicular surgery can be considered predictable, cost-effective alternative to tooth extraction and tooth replacement.

Abstract Introduction: The role of Acetyl -11-keto-β-boswellic acid (AKBA) in regulating osteoblast differentiation was recently brought to light. Therefore, the current study was designed to explore the osteogenic differentiation capability of AKBA on bone marrow mesenchymal stem cells (BMMSCs) as a potential therapeutic agent to accelerate the healing process in apicoectomy. Materials and Methods: BMMSCs were characterized by flow cytometry. Cellular viability and proliferation assays were used with different concentrations of AKBA. Cells were divided into 5 groups to test osteogenic differentiation: Group I: negative control, Group II: positive control, Group III: BMMSCs were treated with 1 μM AKBA, Group IV: BMMSCs were treated with 0.1 μM AKBA, and Group V: BMMSCs were treated with 0.01 μM AKBA. Mineralization assays and gene expression analysis were assessed, and the significance difference between groups was established at P < 0.05. Results: The flow cytometry analysis demonstrated that BMMSCs had positive expression for mesenchymal stem cell marker and negative expression for hematopoietic markers. The concentration of 0.01 μM gave significantly higher cell density than the untreated cells after 7 days (P < 0.05). Cells treated with 0.1 and 0.01 μM AKBA revealed a significantly higher ALP activity, alizarin red, and von Kossa staining than control groups (P < 0.05). High expression of osteogenic genes was detected in BMMSCs treated with 0.1 μM AKBA (P < 0.05). Conclusions: It was declared that the concentration of 0.1 μM AKBA has no toxicity on BMMSC viability and proliferation with an impact on BMMSC osteogenic differentiation. Therefore, AKBA (0.01 μM) could be used in bone regeneration during periradicular surgery.

Background Since 1982, guided tissue regeneration (GTR) has become increasingly popular. The recent progress in GTR research focuses on the application of blood-derived products. However, no comprehensive systematic review has been conducted to assess its effectiveness specifically in periradicular surgery. Therefore, the aim of this review was to analyse the outcomes of periradicular with GTR using blood-derived products compared to standard periradicular surgery. Methods This review was based on randomised controlled trials comparing periradicular surgery in conjunction with GTR with blood-derived products and the standard periapical surgery. The databases searched included Embase, MEDLINE, Cochrane CENTRAL, and Dentistry and Oral Sciences Source, with the most recent search conducted on December 16th, 2022. Additionally, reference lists of similar systematic reviews were examined, while international trials registries and repositories were consulted for unpublished studies. Two blinded independent reviewers carried out the screening and the included studies underwent critical appraisal. The findings are reported in accordance with the PRISMA guidelines. Results A total of 261 publications were initially reviewed based on their title and abstract, resulting in seventeen studies that underwent full-text screening. At this stage, 14 studies were excluded, leaving three randomised controlled trials to be included. These trials involved a total of 85 patients. A meta-analysis was conducted for the outcome of healing. The overall treatment effect was 0.78 (95% CI 0.18 to 3.34), indicating a preference towards the control group. Conclusion Based on a meta-analysis of three studies, there was no statistically significant distinction observed in terms of healing between the GTR involving blood-derived products and standard procedure groups. However, critical appraisal revealed indirectness and imprecision, resulting in a certainty rating of 'low'. Thus, additional robust evidence is necessary to support the utilisation of blood-derived products in GTR techniques to enhance periradicular surgery outcomes. Systematic review registration number PROSPERO CRD42020222663.

Background Since 1982, guided tissue regeneration (GTR) has become increasingly popular. The recent progress in GTR research focuses on the application of blood-derived products. However, no comprehensive systematic review has been conducted to assess its effectiveness specifically in periradicular surgery. Therefore, the aim of this review was to analyse the outcomes of root-end surgery compared to periapical surgery incorporating GTR using blood-derived products. Methods This review involved randomised controlled trials exploring the comparison between GTR utilising blood-derived products and the conventional periapical surgery. The databases Embase, MEDLINE, Cochrane CENTRAL, and Dentistry and Oral Sciences Source were searched, with the most recent search conducted on December 16th, 2022. Additionally, reference lists of similar systematic reviews were examined, while international trials registries and repositories were consulted for unpublished studies. Two blinded independent reviewers carried out the screening and the included studies underwent critical appraisal. The findings are reported in accordance with the PRISMA guidelines. Results A total of 261 publications were initially reviewed based on their title and abstract, resulting in seventeen studies that underwent full-text screening. At this stage, 14 studies were excluded, leaving three randomised controlled trials to be included. These trials involved a combined total of 85 patients. A meta-analysis was conducted for the outcome of healing. The overall treatment effect was 0.78 (95% CI 0.18 to 3.34), indicating a preference towards the control group. Conclusion Based on a meta-analysis of three studies, there was no statistically significant distinction observed in terms of healing between the GTR involving blood-derived products and standard procedure groups. However, critical appraisal revealed indirectness and imprecision, resulting in a certainty rating of 'low'. Thus, additional robust evidence is necessary to support the utilisation of blood-derived products in GTR techniques to enhance periradicular surgery outcomes. Systematic review registration number PROSPERO CRD42020222663.

Correlation Between Proinflammatory Cytokine Expression and Clinical Data in Apical Granuloma

This historical prospective cohort study of the adult population of Sweden is based on data from a national registry: the primary aim was to evaluate the long-term survival of teeth after periradicular surgery. A secondary aim was to identify factors predictive of extraction within 10 years of registration of periradicular surgery. The cohort consisted of all individuals who had undergone periradicular surgery to treat apical periodontitis, as reported to the Swedish Social Insurance Agency (SSIA) during 2009. The cohort was followed until December 31, 2020. Subsequent registrations of extractions were collected for Kaplan-Meier survival analyses and survival tables. The patients' sex, age, dental service provider and tooth group were also retrieved from SSIA. Only one tooth per individual was included in the analyses. Multivariable regression analysis was used and P < 0.05 was considered statistically significant. The reporting guidelines STROBE and PROBE were followed. After data cleaning, and exclusion of 157 teeth, 5 622 teeth/individuals remained for analysis. The mean age of the individuals at the time of the periradicular surgery was 60.5 years (range 20-97, standard deviation 13.31); 55% were women. At the end of the follow-up, that is, up to 12 years, a total of 34.1% of the teeth had been reported as extracted. The multivariate logistic regression analysis, based on follow-up data at 10 years after registration of the periradicular surgery, included 5 548 teeth, of which 1 461 (26.3%) had been extracted. Significant associations between the independent variables tooth group and dental care setting (both P < 0.001) and the dependent variable extraction were found. The highest odds ratio (OR) for extraction applied to tooth group: compared to maxillary incisors and canines, mandibular molars were at greatest risk of extraction (OR 2.429, confidence interval 1.975-2.987, P < 0.001). After periradicular surgery in predominantly elderly people in Sweden, approximately three quarters of the teeth are retained over a 10-year period. The type of tooth is associated with extraction: mandibular molars are at greater risk of extraction than maxillary incisors and canines.

Background and objectives: All surgical procedures produce some secondary effects such as pain, swelling, and some functional impairments like difficulty in chewing mouth opening, speaking, sleeping, etc. Controlling postoperative discomfort may improve the patient's quality of life and acceptance of the treatment. The goal of this randomized single-blind trial was to see if using platelet-rich fibrin during endodontic surgery had a positive impact on pain and other aspects of the patient's quality of life in the first week after surgery. Methods: Fifteen patients with periapical lesions were treated with endodontic surgical procedures (control group). In another 15 patients, platelet-rich fibrin was placed into the bone defect in the form of a clot, and a suture was applied in addition to the surgical procedure (test group). During the first week after surgery, all patients completed a questionnaire to assess their major symptoms and daily activities. The results of the two groups' questionnaires were statistically compared. Results: The test group reported less pain, symptoms (swelling and bad taste), and functional activities compared with the control group but the difference was not statistically significant. Conclusion: The adjunct of platelet-rich fibrin to the endodontic surgical procedure produced some beneficial effects on patients' quality of life during the early postoperative stage. There were insufficient data in the literature and more clinical trials with larger samples have to be carried out in the future to find out the outcome

Background: This study aimed to evaluate the reaction of the periapical tissue to Cold ceramic and mineral trioxide aggregate (MTA) following periapical endodontic surgery. Materials and Methods: In this experimental study, a total of 12 mandibular first, second, and third premolars of two male dogs were selected. All procedures were performed under general anesthesia. The access cavities were prepared, and the length of canals was determined. Root canal treatment was performed. A week later, periradicular surgery was performed. After osteotomy, 3 mm of the root end was cut. Then, a 3-mm cavity was created by an ultrasonic. The teeth were randomly divided into two groups (n = 12). The root-end cavities were filled with MTA in the first group and with Cold ceramic in the second group. After 4 months, the animals were scarified. Histological evaluation of the periapical tissues was performed. Data were analyzed using SPSS 22 and Chi-square test and P = 0.05. Results: The findings showed 87.5% and 58.3% cementum formation in MTA and Cold ceramic groups, respectively, indicating a significant difference (P &lt; 0.001). In addition, the results showed 91.7% and 83.3% bone formation in MTA and Cold ceramic groups, respectively, but the difference was not statistically significant (P = 0.6). Furthermore, the findings revealed 87.5% and 58.3% periodontal ligament (PDL) formation in MTA and Cold ceramic groups, respectively (P = 0.05). Conclusion: Cold ceramic was able to induce the regeneration of cementum, bone, and PDL; hence, it can be considered as a biocompatible root-end filling material in endodontic surgery.

Guided tissue regeneration in peri-radicular surgery

Background. Periradicular surgery is the last treatment option for teeth with persistent periradicular endodontic lesions. This study aimed to assess the adhesion of fibroblasts to root dentin conditioned with ethylenediaminetetraacetic acid (EDTA), MTAD, and QMix.Methods. Twelve dentin discs were fabricated of 6 human single-rooted teeth. Fibroblasts were isolated from the periodontal ligament (PDL) of a premolar tooth. The teeth were healthy and freshly extracted from the socket. The samples were divided into four groups for surface conditioning with (I) EDTA, (II) MTAD, (III) QMix, and the control group. Fibroblasts were cultured on conditioned dentin discs at 37°C, 95% air, and 5% CO2 for 4 hours and then rinsed with PBS three times to eliminate unattached cells from the surface. The mean counts of attached cells were calculated using a Neubauer chamber. Also, the attachment of fibroblasts was evaluated using scanning electron microscopy (SEM).Results. The mean counts of fibroblasts attached to root dentin in EDTA, QMix, MTAD, and control groups were 303±46, 243±41, 213±33, and 347±38, respectively. No significant difference was noted in the number of fibroblasts attached between MTAD, EDTA, and QMix and the control group (P>0.05). Under SEM, the fibroblasts were flat and spindle-shaped, with cytoplasmic processes covering the untreated dentin surface. In the experimental groups, the cells were rounder with fewer processes. All the three groups showed weaker adhesion to dentin compared to the control (untreated dentin) group.Conclusion. Under the limitations of this study, it was concluded that treating the dentin surface with EDTA, MTAD, or QMIX might not be an effective way to improve the adhesion of human PDL fibroblasts.

Evidence-informed decision-making in health care relies on the translation of research results to everyday clinical practice. A fundamental requirement is that the validity of any healthcare intervention must be supported by the resultant favourable treatment outcome. Unfortunately, differences in study design and the outcome measures evaluated often make it challenging to synthesize the available research evidence required for secondary research analysis and guideline development. Core outcome sets (COS) are defined as an agreed standardized set of outcomes, which should be measured and reported as a minimum in all clinical trials on a specific topic. The benefits of COS include less heterogeneity, a reduction in the risk of reporting bias and ensuring all trials contribute data to facilitate meta-analyses; given the engagement of key stakeholders, it also increases the chances that clinically relevant outcomes are identified. The recognition of the need for COS for assessing endodontic treatment outcomes leads to the development of Core Outcome Sets for Endodontic Treatment modalities (COSET) protocol, which is registered (No. 1879) on the Core Outcome Measures in Effectiveness Trials (COMET) website. The objectives of this scoping review are to: (1) identify the outcomes assessed in studies evaluating surgical endodontic procedures; (2) report on the method of assessment used to measure the outcomes; (3) and assess selective reporting bias in the included studies. The data obtained will be used to inform the development of COS for surgical endodontics. A structured literature search of electronic databases and the grey literature was conducted to identify systematic reviews on periradicular surgery (PS), intentional replantation (IR) and tooth/root resection (RR), published between January 1990 and December 2020. Two independent reviewers were involved in the literature selection, data extraction and the appraisal of the studies identified. The type of intervention, outcomes measured, type of outcomes reported (clinician- or patient-reported), outcome measurement method and follow-up period were recorded using a standardized form. Twenty-six systematic reviews consisting of 19 studies for PS, three studies for IR and four studies for RR were selected for inclusion. Outcome measures identified for PS and IR included pain, swelling, mobility and tenderness, outcomes related to periodontal/soft tissue healing (including sinus tract), periradicular healing, tooth survival, life impact (including oral health-related quality of life), resource use and/or adverse effects. For RR, in addition to tooth survival, endodontic complications and adverse effects, the outcome measures were primarily periodontal-related, including pocket depth reduction, attachment gain, periodontal disease and periodontic-endodontic lesions. The majority of outcome measures for PS, IR and RR were assessed clinically, radiologically and/or via patient history. Specific tools such as rating scales (Visual Analog Scale, Verbal Rating Scale, Numerical Rating Scale and other scales) were used for the assessment of pain, swelling and tenderness, and validated questionnaires were used for the assessment of oral health-related quality of life. The range of follow-up periods was variable, dependent on the outcome measure and the type of intervention. Outcome measures, method of assessment and follow-up periods for PS, IR and RR were identified and categorized to help standardize the reporting of outcomes for future research studies. Additional outcome measures that were not reported, but may be considered in the COSET consensus process, include loss of root-end filling material, number of clinic visits, surgery-related dental anxiety and mucogingival aesthetic-related measures, such as scarring, black triangles, root surface exposure and tissue discoloration. COMET (No. 1879).

Inspired by several other surgical disciplines, the quest for treating diseases through minimally invasive procedures has permeated endodontics, but not without controversy. Indeed, pulp amputation/excision and root-end resection are akin to surgical procedures elsewhere in the body and therefore, an increasing number of studies have addressed the "potential" to adopt such minimally invasive procedures in root canal treatment, with the larger goal of conserving tooth tissue for long-term survival of treated teeth. Yet, it is undeniable that this "trend" has been met with immense resistance with unclear evidence to strongly support or refute this philosophy. One may view root canal treatment as having two important procedural parts: (i) gaining access to the root canal and (ii) achieving clean root canals to remove the necrotic/infected or irreversibly inflamed tissues and then fill the space that was occupied by the pulp tissue and subsequently enlarged during cleaning and shaping, which should result in two key long-term outcomes: (i) healing of periradicular periodontitis and (ii) survival/retention of the tooth. Whilst a lot of interest has been directed towards gaining access through minimally invasive cavity designs, it is surprising that little effort has been expended on studying minimally invasive root canal preparation or surgical intervention. The aim of this review is not to promote or denigrate these philosophies, but to provide a balanced overview of the concepts, currently available evidence and future perspectives on minimally invasive endodontics from the context of root canal preparation and surgical endodontics. Specific attention is given to the role of modern irrigation strategies in potentially improving canal cleanliness even when canals are minimally prepared and the areas of research that are currently lacking in this topic.

Treatment decisions for a heavily restored endodontically treated tooth vary amongst clinicians owing to multitude of factors. This phenomenon not only often poses dilemmas to clinicians of different clinical backgrounds, but also exerts a degree of treatment difficulty to the treating clinician. Previous studies indicated that specialty training and clinical experience significantly impacted clinical decision-making process. Master of Science postgraduate students in endodontics, prosthodontics, periodontics, oral surgery and implantology participated in a questionnaire-based cross-sectional study. The dental specialties were further categorised into restorative and surgical dentistry. A multiple-choice questionnaire with three clinical cases was distributed to the students. Data were analysed for trends using descriptive statistics. There was a 44% response rate; the majority of respondents were from restorative dentistry specialties. Cases 1 and 2 were rated as moderate to high difficulty, and Case 3 was predominantly rated as high difficulty with procedure predictability being the main factor affecting their clinical decision-making in three cases. Endodontic retreatment was selected as the preferred treatment in Cases 1 and 2 and periradicular surgery in Case 3. The students were fairly confident in managing Cases 1 and 2, but not in Case 3. Referral patterns were consistent in Cases 1 and 2 with endodontists being the first choice of referral except for Case 3 where 48% preferred to refer to oral surgeons and 35% choosing endodontists. Some indication of differences between specialties were noted throughout. Years in practice appeared to be related to the importance of predictability in Case 3 only. Considerable inter-clinician variability was noted whereby specialty postgraduate training impacted on clinical decision-making. Overall, procedural predictability, technical difficulty, risk of damage to the tooth and patient preference were the most highly ranked factors affecting clinical decision-making. Evidence-based treatment guidelines and dental curricula should be reviewed to enhance inter-clinician agreement in clinical decision-making, ultimately improving patient care.

Background: Intra-oral bony defects following periradicular surgery have been documented to have high selfregenerating potential (especially when small). However, early permanent rehabilitation of tooth to function is important post-surgery. Thus, there is a need to enhance bone healing through regeneration due to the prolonged natural bone healing process. Many materials have been proposed and used but the Platelet-rich fibrin (PRF); a second-generation platelet with fibrin membranes enriched with platelets growth factors is an autologous material, easy to produce and a cost-effective way of regenerating bony defects. Aim: To assess and report the regenerative potential of PRF following periradicular surgery. Methodology: A case report of a 60-year old female who presented with a chronic periapical abscess in relation to the upper right incisors. A periapical pathology of 30mm in its widest dimension was present on the radiograph. Following root canal treatment, the patient had periradicular surgery to remove the apical cystic lesion. The bony defect was filled with autologous platelet-rich fibrin (produced through centrifuging of peripheral blood) to stimulate bone regeneration, and the tooth was reviewed for one year. Result: The one-year review post periradicular surgery showed good healing and bone regeneration. Conclusion: The report showed the use of PRF in regeneration of intra bony defect post degranulation of periapical lesion (after removal of cystic lesion) as an effective and cheap way of achieving regeneration.

Objective: was directed to evaluate platelet rich fibrin alone and in combination with xenograft as an alternative to bone substitute in treatment of critical sized bone defects in dogs. Material and methods:8 dogs were selected for this study in which diabetes mellitus was induced. Root canal treatment was done in the 2nd and 4th premolar teeth of both sides then 4 critical sized bone defects were created in relation to the distal root of the selected teeth. According to the bone cavity filling materials there was 4 groups xenograft, xenograft and PRF, PRF and blood clot groups. Dogs were sacrificed at 4 days,2,5and 9 weeks the mandibles were harvested for DEXA evaluation. Results: bone density measurement at 9 weeks was significant with Xenograft and PRF group than Xenograft, PRF and blood clot groups, and at the same time there was no significance between Xenograft and PRF groups. Conclusion: PRF is a valuable material that can be used as a sole grafting material in periradicular surgery to improve bone regeneration.