Surgical Endodontic Treatment Research Articles

Factors Affecting the Outcome of Periapical Surgery; a Prospective Longitudinal Clinical Study

Wound healing following periapical surgery is influenced by age, gender, smoking, periapical lesion size, type of root-end filling, method of root-end cavity preparation and the use of microsurgical or conventional technique. This study aimed to evaluate the influence of various preoperative factors such as age, gender, smoking, preoperative pain, and preoperative periapical lesion size on the outcome of surgical endodontic treatment. A thorough history, examination, and investigation were performed to establish patient age, gender, smoking status, periapical lesion size, and the presence of preoperative pain. Forty patients aged between 15–57 years presented with persistent chronic apical periodontitis of single-rooted anterior teeth after conventional re-root canal treatment were enrolled for periapical surgery. Following periapical surgery, all patients were recalled for evaluation of periapical healing after 12 months based on clinical and periapical X-ray examination due to inaccessibility of an advanced imaging system (CBCT). Chi-squared and Fisher’s exact test were applied, which revealed a statistically significant association of periapical healing with age (p = 0.025), smoking (p = 0.029), and lesion size (p < 0.001). Although, the success of periapical healing was higher in males 78.6% (22/28) compared to females 58.3% (7/12) however, no statistically significant relationship was found between gender and healing (p = 0.254). Patient age, smoking status, and size of the preoperative lesion had a strong influence on periapical healing after surgical endodontic treatment.

Baseline MMP expression in periapical granuloma and its relationship with periapical wound healing after surgical endodontic treatment

BackgroundMatrix metalloproteinases (MMPs) catalyzes the degradation of the extracellular matrix components and have a major role in many physiological processes including wound healing. In the current study, we examined the correlation of baseline MMPs 1, 2, 7, and 9 expressions with periapical wound healing after surgical endodontic treatment.Methods27 patients aged between 15 and 57 years presenting with chronic apical periodontitis or chronic apical abscess of an anterior tooth with previously attempted or failed root canal treatment were included in this study. During surgical endodontic treatment, tissue from the periapical lesion sample was collected and used for gross histopathological analysis as well as mRNA expression analysis of MMPs 1, 2, 7, and 9. Patients were recalled for follow-up after 6 months to evaluate the healing status both clinically and radiographically and healing was correlated with baseline MMP expression.ResultsOut of 27 patients, healing was observed in 15 patients at the end of 6 months, and in 21 patients after 12 months.. Six patients showed no healing even after 12 months. Analysis of baseline MMP 1, 2, 7, and 9 expression levels with healing status showed the mean relative expression of MMP2 and MMP9 to be considerably increased in the non-healing group as compared to the healing group.ConclusionOverexpression of MMP2 and MMP9 may be considered as a potential prognostic biomarker for periapical wound healing after surgical endodontic treatment. However, further studies are desirable to establish its precise relationship with periapical wound healing.

Adjunctive use of antimicrobial photodynamic therapy in the surgical treatment of periapical lesions: A case series

BackgroundAntimicrobial photodynamic therapy (aPDT) is used in endodontics to improve orthograde root canal disinfection as an adjunct to standard treatments. Conversely, evidence concerning the application of aPDT in retrograde endodontic surgery is limited. Thus, the aim of the present study was to provide additional data regarding the use of aPDT in the surgical endodontic treatment of periapical lesions. MethodsA total of 25 consecutive patients presenting teeth with periapical radiolucency eventually associated with clinical signs and symptoms of apical periodontitis were included. Following access flap completion, osteotomy, mechanical debridement, root apical third resection, and preparation of the root-end cavity, aPDT was applied to decontaminate the surgical site using phenothiazine chloride dye at a concentration of 10 mg/mL and irradiation with a hand-held 100-mW diode laser with a wavelength of 660 ± 10 nm. At the latest follow-up visit, healing was evaluated as successful, uncertain, or failure according to well-established clinical and radiological criteria. ResultsOverall, 31 periapical lesions were treated with aPDT. Healing proceeded uneventfully. The mean follow-up time was 36.19 months, with times ranging from 12 to 85 months. A total of 25 (80.65%) cases were classified as successful, 5 (16.13%) as uncertain, and only one (3.22%) as failure. Irrespective of the treatment outcome, all treated teeth were still functional, with no symptoms reported by the patients. ConclusionaPDT as an adjunctive treatment modality in the surgical endodontic treatment of periapical lesions showed promising medium-term results associated with preservation of all diseased teeth.

Influence of Root Canal Fillings on Alveolar Bone Crest Level—An Observational Cross Sectional CBCT Analysis

The aim of this study was to compare the alveolar bone crest (ABC) level of root canal filled (RCF) teeth without apical periodontitis with corresponding non-filled teeth in the same individual using three-dimensionally cone-beam computed tomography (CBCT) data. Two hundred and thirty-five matching pairs of RCF teeth and corresponding teeth without RCF were selected from a pool of 580 random CBCT-images (voxel size 160–200 µm). Teeth with apical periodontitis, perio-endodontic lesions or surgical endodontic treatment were excluded. The distance between the cemento–enamel-junction (CEJ) and the ABC was assessed centrally mesial, distal, palatal/lingual and buccal at each tooth (∑1880 measuring points) in a standardized manner. Topographic, gender, and age-related relationships were also noted. Data were analyzed using the Kruskal–Wallis-test. The ABC-level between RCF teeth (2.64 ± 1.25 mm) and teeth without RCF (2.61 ± 1.16 mm) did not differ significantly (p > 0.05). No differences concerning localization (maxilla/mandible, tooth type) and gender (p > 0.05) occurred. Overall, ABC-level in the maxilla (2.74 ± 1.48 mm) was significantly lower (p < 0.001) compared to mandibular teeth (2.50 ± 1.41 mm). Patients > 41 years had significantly lower ABC-levels than younger patients (p < 0.05). Men showed a reduced bone level compared to women (p < 0.05). In conclusion, RCF teeth are identical to their non-RCF counterparts, at least in terms of crestal bone level, regardless of the location or type of tooth and the gender of the patient. Thus, root canal treatment is an essential pillar for long-term tooth preservation.

A questionnaire survey of dental practitioner to determine knowledge and awareness about prescribing antibiotics during and after endodontic treatment in Central India

Endodontic infections are polymicrobial involving a combination of gram-positive, gram-negative, facultative anaerobes and strictly anaerobic bacteria. Thus, antibiotics, account for the vast majority of medicines prescribed by dentists. The inappropriate and excessive use of antibiotics is a major factor in the emergence of antibiotic resistance. Dentistry’s contributions to the problem of antibiotic resistance can be important because dentists prescribe 10% of all general antibiotics. Till date, sparse literature is available in central India regarding the usage of prescribing antibiotics for endodontic treatment. Aim: The aim of this study is to determine knowledge about prescribing antibiotics during and after endodontic treatment amongst dental practitioners in Central India. Method: A Web-based survey of 110 participants was conducted using validated questions in a population of central India. Results: Amoxicillin (72.3%) was the drug of choice by most of the practitioner’s (no medical allergies).Antibiotic usage was reported highest for surgical endodontic treatment (64.1%),but clinical scenario like pulpitis(5.8%) and necrosis (9.6%) also reports antibiotic prescription. Over prescription of antibiotic was seen when antibiotics were prescribed for cases where no improvement was seen with the previously prescribed antibiotic. Awareness regarding drug resistance was reported 86.7%. Conclusion: Though practitioner shows fair knowledge about the prescription of antibiotic there is need to re- evaluate drugresistance. Keywords: Antibiotic, Antibiotic Resistance, Antibiotic prescription, Endodontic infection, Endodontic treatment.

TRATAMENTO DAS LESÕES ENDO-PERIODONTAIS: UMA REVISÃO DE ESCOPO

As lesões endo-periodontais são lesões destrutivas que acometem o tecido periodontal e pulpar de um determinado dente. O diagnóstico e o tratamento dessas lesões representam um grande desafio na prática clínica. Logo, o objetivo desta revisão foi responder a seguinte pergunta foco: “Quais são os protocolos de tratamento para as lesões endo-periodontais?” Uma revisão de escopo foi realizada de acordo com as normas PRISMA-ScR. A base de dados MEDLINE (pubmed) foi pesquisada até agosto de 2020. Foram procurados estudos com qualquer desenho que relataram o tratamento endodôntico e periodontal de pelo menos um dente com lesão endo-periodontal. A busca eletrônica gerou 238 títulos/resumos e 44 artigos foram incluídos nesta revisão. No total, 545 voluntários foram incluídos e 651 dentes foram diagnosticados/tratados como lesões endo-periodontais. A terapia de maior prevalência foi o tratamento endodôntico convencional antes da terapia periodontal cirúrgica, seguido pelo tratamento endodôntico cirúrgico sendo realizado ao mesmo tempo que o tratamento periodontal cirúrgico, e em menor proporção a terapia periodontal não cirúrgica antes da terapia endodôntica. Não existiram relatos de casos onde o tratamento periodontal cirúrgico ocorreu antes da endodontia convencional. Em conclusão, o tratamento das lesões endo-periodontais deve envolver tanto a terapia endodôntica quanto a periodontal. A maioria dos casos relatados iniciou o tratamento pela endodontia convencional e seguido pelo tratamento periodontal (não-cirúrgico e/ou cirúrgico). Porém, ainda existe controvérsia se deve ser aguardado um tempo de reparo entre os dois tratamentos. A maioria dos dentes diagnosticados com algum tipo de lesão endo-periodontal e tratados tem resultados positivos.

SUCCESSFUL NON SURGICAL MANAGEMENT OF A LARGE PERIAPICAL LESION – TWO CASE REPORTS

Aim: The aim of these case reports is to emphasize the successful healing of large periapical lesions using non surgical endodontic treatment with advanced techniques Background: Periapical lesions of endodontic origin are common pathological conditions affecting the periradicular tissues. The primary objective of root canal treatment is to cure or prevent periradicular periodontitis and to retain natural teeth in function and aesthetics Case description: Two case reports of large periapical lesions are described here which have shown favourable clinical and radiographic outcome following non surgical endodontic therapy Conclusion: Size of a periapical lesion does not necessarily mandate surgical intervention always and has shown the potential to heal following conservative endodontic therapy. Assessment of healing of a large periapical lesion necessitates a long term follow up and has to be done periodically. Clinical significance: The article highlights that present day endodontic treatment has become predictable and highly successful due to the advancements in diagnostic imaging techniques, rotary instruments, irrigants , intracanal medicaments and obturation systems which has in turn led to the fall in root end surgeries

PERSISTENT APICAL PERIODONTITIS AFTER ENDODONTIC TREATMENT: SURGICAL MANAGEMENT

The high success of endodontic therapy for apical periodontitis treatment is well known. However, studies showed that between 20% to 60% of treated teeth in the population present with apical periodontitis after root canal therapy. When viable, non-surgical retreatment is the rst option while endodontic surgery should be the last resource for elimination of the disease. The aim of this case report is emphasize the potentiality of the successful outcome of surgical endodontic treatment following failed non-surgical treatment of a second maxillary premolar and rst maxillary molar

Gingival Recession after Surgical Endodontic Treatment and Quality of Life: A Systematic Review and Meta-analysis.

This systematic review addressed flap designs in endodontic surgery which can have an impact on the Oral Health Related Quality of Life (OHRQoL). Four electronic databases were searched (PubMed, Cochrane Library, Web of Science, and Scopus) to identify all studies up to November 2019 that investigated the effect of flap designs on gingival recession and quality of life among healthy adults. The initial search identified 2701 references. Ten studies were included in this systematic review; two were randomised clinical trials and eight were non-randomised clinical trials. Studies showed that sulcular incision increases the risk of gingival recession and decreases OHRQoL. Two studies were included in the meta-analysis in relation to gingival recession. The pooled results demonstrated that submarginal incision showed a decreased weighted mean difference in gingival recession by 0.31 mm (95% CI: 0.12 - 0.51) (p = 0.002) compared to sulcular incision. Sulcular incision flap unfavourably affect the level of gingiva and OHRQoL. All nonrandomised studies had a statistically significant bias and the sample sizes in all studies were relatively small. More gingival recession and lower OHRQoL were associated with sulcular incision. Additional investigations are warranted to provide more evidence.

Computer-aided design-CAM-guided endodontic microsurgical localization and retrieval of two separated instruments from the periapical area of a mandibular second molar

Three-dimensional (3D) imaging devices used for the visualization of anatomic structures not only allow for a more accurate diagnosis but also facilitate precise planning of surgical treatments, such as in guided surgery for instrument retrieval using templates. The innovative template-based treatment methods could also play a crucial role in future modern surgical endodontic treatments, enabling exact preplanning and precision-guided surgical interventions, and resulting in greater accuracy and success rates. We present here a case of a patient with a periapical lesion below a right mandibular second molar, with a fractured file segment extruding beyond the apex in the distal canal, and another instrument half-way extruded from the mesial canal, with radiolucencies evident at the mesial and distal root apices. The patient was treated by employing a 3D-guided microsurgical approach. First, 3D optical scans were imported into a guided surgery program. Periapical lesions and extruded fractured instruments were marked within the software. The osteotomy size, apical resection level, and bevel angle were defined pretreatment. This case introduces a novel-guided microsurgical endodontic technique, incorporating recommended guidelines of modern surgical endodontic treatment with the aid of 3D-printed surgical templates, by which minimally invasive surgical treatment was ensured with preservation of tooth, bone, and surrounding anatomical structures.

Surgical endodontic management after conventional root canal treatment failure: A case report

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. Keywords: Apicoectomy, Retreatment, Biodentine, Ultrasonic retrotips.

Management of an unusual foreign body in periapical tissues of immature permanent maxillary central incisor

Root canal treatment of an immature tooth is a significant challenge because of the size of the canal, the thin and fragile dentin walls, and the large open apex. The present report describes a clinical case of apical surgery with a 3-year clinical and radiographic follow-up in an immature permanent maxillary central incisor with persistent apical periodontitis caused by a foreign body in the periapical tissues. Surgical endodontic treatment should be seen as the best choice for treating persistent apical periodontitis. This treatment can manage the infection source and provide a direct hermetic seal of the apical area.

Isthmuses, accessory canals, and the direction of root curvature in permanent mandibular first molars: an in vivo computed tomography study.

ObjectivesThis study was performed to assess the anatomy of mandibular first molars.Materials and MethodsIn this in vivo study, cone-beam computed tomography (CBCT) volumes of 312 bilateral intact first mandibular molars from 156 patients (79 men and 77 women; average age, 35.6 ± 11.2 years) were investigated in terms of the direction of each canal's curvature in the buccolingual and mesiodistal dimensions (direction of the position of the apex in relation to the longitudinal axis of the root), the presence of an isthmus (a narrow, ribbon-shaped communication between 2 root canals) in 3 segments (0–2, 2–4, and 4–6 mm) from the apex), and the presence and number of accessory canals (smaller canals besides the main root canals, connecting the pulp to the periodontium). Data were analyzed statistically (α = 0.05).ResultsMesiolingual canals were mostly buccally and distally inclined, while mesiobuccal and distolingual canals were mostly distally curved. Isthmuses were more common in younger patients (χ2 test, p < 0.05). The average numbers of accessory canals in the apical, middle, and coronal segments were 9.9 ± 4.2, 6.9 ± 2.9, and 9.3 ± 3.0 canals per segment, respectively (analysis of variance, p < 0.001). Age and sex were not associated with the number of accessory canals (p > 0.05).ConclusionsThe complex anatomy of these teeth deserves attention during non-surgical or surgical endodontic treatment. Around the apex, isthmuses might be more prevalent in younger and female individuals.

Endodontic Periapical Lesion: An Overview on the Etiology, Diagnosis and Current Treatment Modalities.

Nonsurgical and surgical endodontic treatments have a high success rate in the treatment and prevention of apical periodontitis when carried out according to standard and accepted clinical principles. Nevertheless, endodontic periapical lesions remain in some cases, and further treatment should be considered when apical periodontitis persists. Although several treatment modalities have been proposed for endodontically treated teeth with persistent apical periodontitis, there is a need for less invasive methods with more predictable outcomes. The advantages and shortcomings of existing approaches for the diagnosis and treatment of endodontic periradicular lesions are discussed in this review.

Clinical, radiographic, and histological findings of chronic inflammatory periapical lesions - A clinical study.

Aim:The present study aimed at comparing clinical, radiographical, and histological findings in chronic periapical lesions such as cysts, granuloma, and abscess.Methodology:The present study was conducted on 148 teeth having chronic inflammatory periapical lesions with or without nonsurgical endodontic treatment. Endodontic surgery was performed by single trained endodontist. After surgical endodontic treatment, biopsy sections of teeth were assessed histologically. All slides stained with hematoxylin/eosin and Gomori trichrome for light microscopy assessment.Results:Out of 148 teeth, 41 had chronic inflammatory lesions, 34 had inflammatory cysts, and 25 had indefinite lesions. Chronic inflammatory lesions assessed histologically found chronic apical periodontitis in 86 cases and inflammatory cysts in 62 cases. The difference was significant (P < 0.05). Out of 86 cases of chronic apical periodontitis confirmed clinical radiographically, 64% found positive, whereas 36% were not histologically. Out of 62 cases of inflammatory cysts confirmed clinically and radiographically, 78% found positive while 36% were not histologically. Out of 25 indefinite lesions, 56% found chronic inflammatory lesions while 44% found inflammatory cyst.Conclusion:There was significant disagreement in clinical radiographic as well as histological diagnosis.

Intentional Replantation to Treat Apical Periodontitis of Maxillary First Molar with Foreign Body Located Outside Apical Foramen Using CBCT: A Case Report

The recent use of cone beam computed tomography (CBCT) in the field of dentistry to obtain 3-dimensional (3D) images has enabled more effective examination and diagnosis in endodontic treatment. Such information has also been reported to be of benefit in surgical endodontic treatment such as intentional replantation. Here, we report a case of intentional replantation with the assistance of CBCT in which a good therapeutic outcome was achieved. The patient was a 30-year-old woman who visited our hospital with the chief complaint of spontaneous pain in the right maxillary first molar. Dental radiographs revealed a radiolucent area in the apical portion of the distal root, and a radiopaque area thought to be a broken shard from a small surgical instrument measuring approximately 1.5 mm in length. The shard was located outside the distal apical foramen. Based on these findings, the diagnosis was acute suppurative apical periodontitis of the right maxillary first molar. Infected root canal therapy was subsequently commenced. The patient's symptoms showed no improvement, however, and the pain persisted. Therefore, dental CBCT was performed to obtain 3D images, which confirmed a radiopaque area thought to be a broken shard from a small surgical instrument located outside the apical foramen of the distal root and facing in a direction that made it impossible to remove from the root canal. Because the patient's symptoms had shown no improvement and a foreign body was observed outside the apical foramen, intentional replantation combined with root resection was performed with informed consent. At a 1-year follow-up visit, progress was good, and there were no reported symptoms or signs. When reaching a diagnosis is difficult based on clinical findings and dental radiographs alone, the 3D images provided by CBCT offer a means of securing a more reliable diagnosis, allowing planning of treatment to be more effective.

Surgical Endodontic Treatment of Radicular Cyst Associated with Periapical Osteoperiostitis in a Maxillary Molar: A Case Report

Surgical Endodontic Treatment of Radicular Cyst Associated with Periapical Osteoperiostitis in a Maxillary Molar: A Case Report

The causes of subcutaneous emphysema of relevance to dental practitioners?

Data sources An electronic search was conducted using EMBASE, LILACS, PubMed, SciELO, Scopus, Web of Science, and two grey literature data sources. All issues of nine dentistry journals and relevant chapters in four endodontic textbooks were manually searched.Study selection Abstracts of all the studies that were identified during the electronic and manual searches were obtained and screened independently by two reviewers in order to select clinical studies, case series, or case reports describing subcutaneous emphysema that occurred in adult patients during or immediately after root canal treatment.Data extraction and synthesis Predetermined data were extracted from each study independently by two reviewers and organised into data tables. All disagreements were resolved through discussion with a third reviewer. The data obtained were combined through a narrative synthesis.Results Following full-text evaluation according to the inclusion criteria, 51 articles that described 65 cases of subcutaneous emphysema were included. There were 36 case reports and 15 case series. The condition was mainly reported in female patients and maxillary teeth. While the age of the patients ranged from 18 to 63 years, this demographic information was missing from a few studies. Details on the involved tooth and diagnosis were also missing from several articles. In most of the cases, subcutaneous emphysema developed during initial root canal treatment. The diagnosis was mainly based on intraoral, plain facial, neck, or chest radiographs, while computed tomography (CT) scans were obtained in fewer cases. The majority of the patients were referred to a different practice, a hospital or university clinic for the management of the condition by more specialised healthcare practitioners. In addition to drying root canals using air pressure, irrigation with hydrogen peroxide, and the air-water spray produced by handpieces, it was reported that laser-produced spray and ozone gas infiltration may also be the culprits of subcutaneous emphysema. The signs and symptoms resolve within 17 days. Its management mostly remains empirical and involves the use of antibiotics, analgesics, local application of cold or hot compresses, or administration of oxygen and hospitalisation, among other methods.Conclusions The systematic review showed that subcutaneous emphysema can occur during both surgical and nonsurgical endodontic treatment. Air streams or air-water sprays should not be directed toward the root canals or areas with mucosal discontinuity. None of the management approaches were clearly associated with a faster recovery. The review asked for developing guidelines in order to avoid unnecessary or potentially harmful interventions.

Evaluation of the dislodgement resistance of bioceramic reparative cements placed in a retrograde cavity using a different technique

Aim: Calcium silicate-based fillings have been widely used in surgical endodontic treatment because of hard-tissue conductive and inductive properties. The aim of present study is to investigate the bond strength of different calcium silicate-based fillings in retrograde cavities. Methods: Forty-four maxillary single rooted teeth were endodontically treated. The apical portions of the teeth were removed and root-end cavities were prepared using an ultrasonic tip. The roots were randomly divided into four experimental groups (n = 11) according to the material used; (1) MTA-FILLAPEX, (2) MTA Repair HP, (3) MTA-FILLAPEX+ MTA Repair HP, and (4) MTA Plus. Two horizontal cross sections (1±0.1 mm thick) from each specimen were resected from the apices. These sections were placed in a universal testing machine to evaluate the push-out bond strength force required for dislodgement of the root end filling was recorded. The failure type was also evaluated by using a stereomicroscope. The differences in bond strength were analyzed using the two-way analysis of variance (ANOVA). Results: MTA-FILLAPEX and MTA Plus displayed the lowest and highest dislocation resistance, respectively (P &lt; 0.05). In the apical level, bond strength was significantly higher than the coronal level in all groups except for MTA-FILLAPEX. Mixed failure was prevalent in all groups, except for MTA-FILLAPEX, which showed purely cohesive failures. Conclusions: Investigated calcium silicate-based filling materials showed different bond strength to the root-end cavity. The bond strength was significantly decreased when the prior application of MTA-FILLAPEX before delivery of MTA Repair HP.

Endodontic Microsurgery Using Dynamic Navigation System: A Case Report

Dynamic navigation systems were introduced to facilitate dental implantology by improving the accuracy of dental implant positioning. Dynamic navigation integrates surgical instrumentation and radiologic images by using an optical positioning device controlled by a dedicated computerized interface. These features could help in reducing the risk of unintentional iatrogenic damage to nearby anatomic structures and perform minimally invasive or flapless surgery, leading to reduced patient postoperative discomfort and improved healing. The present case report showed the use of the Navident dynamic navigation system (ClaroNav, Toronto, Ontario, Canada) by an undergraduate student for bone cavity preparation and root-end resection in the surgical endodontic treatment of a lesion in an upper lateral incisor. The system allowed precise localization of the root and precise apicoectomy with a minimal invasive cavity. The dynamic navigation system allowed the student to precisely direct the bur in 3 dimensions. The osteotomy and root-end resection were easily and quickly performed by the undergraduate student with a minimally invasive approach without iatrogenic errors. The navigation system allowed the operator to precisely perform a minimally invasive osteoctomy and root-end resection during endodontic surgery. The development of dedicated surgical navigation systems for endodontic surgery could facilitate the operator's maneuvers and reduce the risk of iatrogenic errors.