AIM To evaluate two- and three-dimensionally the effect of resorbable collagen-based bone-filling material on periapical healing of endodontic lesions with four-wall defects following endodontic microsurgery (EMS). METHODOLOGY This parallel, randomized controlled superiority clinical trial involved 86 lesions with the strictly endodontic origin and four-wall defect morphology. EMS procedures were performed by calibrated postgraduate residents. Before flap closure, osteotomies were randomized to the control or treatment group. In the control group, the flap was repositioned with no material added. In the treatment group, a collagen-based bone-filling augmentation material was placed into the osteotomy. Clinical and radiographic examinations were completed after 12 months. Periapical healing was evaluated by blinded evaluators using periapical (PA) radiographs according to Molven's criteria and cone beam computed tomography (CBCT) scans according to PENN's 3D criteria. Cortical plate healing was scored according to the RAC/B index. The data were analysed using Fisher's exact test, Logistic regression models and Chi-squared test. The significance level was predetermined at p < .05. RESULTS Sixty-six cases were evaluated at the 12-month follow-up, with 30 and 36 cases in the control and treatment groups, respectively. Only the asymptomatic cases (control = 26, treatment = 32) were included in the radiographic evaluation. Twenty-three cases (88.5%) in the control and 28 (87.5%) cases in the treatment group demonstrated complete healing on PA radiographs (p = 1.000). On CBCT, 10 (38.4%) and 21 (65.6%) cases had completely healed in the control and treatment groups, respectively (p = .095). The re-establishment of the buccal cortical plate was detected in 12 (46.2%) and 22 (68.8%) cases in the control and treatment groups, respectively (p = .243). CONCLUSION Within the limitations of the present study, the use of collagen-based bone-filling material had no statistically significant effect on the periapical healing of endodontic lesions with four-wall defect following EMS at the 12-month follow-up when evaluated by PA radiographs or CBCT scans. However, the observed higher percentage of a re-established cortical plate in the treatment group could suggest a clinical benefit that is of interest after surgical endodontic treatment.

BACKGROUND:The authors' aim was to describe 2 endodontically treated mandibular first premolars with apical and mesiolingual radiolucencies on radiographs with different approaches that were resolved with intentional replantation.CASE DESCRIPTION:In case 1, a 58-year-old man reported biting sensitivity on endodontically treated mandibular first premolar with good quality restorations. A periapical radiograph (PAX) and cone-beam computed tomography (CBCT) image revealed 2 low-density areas located at the apical and mesiolingual aspects of the root. A radicular groove accessory canal was noted on the mesial root surface during intentional replantation. The patient has been asymptomatic. At a 3-year follow-up, complete healing was observed on PAX and CBCT images. In case 2, a 40-year-old woman reported pinching pain of her mandibular right quadrant that returned a few months after initial root canal treatment. Radiographs revealed periapical radiolucency at the apexes of the mandibular first premolar with a missed lingual canal. Nonsurgical retreatment was performed in 2 visits with calcium hydroxide dressing. Two months later, endodontic microsurgery was performed owing to ongoing symptoms. In addition, CBCT images showed extensive bone loss on the mesiolingual aspect of the root. Intentional replantation was performed 2 weeks later because she had intolerable pain. A radicular groove accessory canal was observed on the mesial root surface during the procedure. The patient reported substantial relief of pain. The radiolucencies healed by the 25-month follow-up as observed on PAX and CBCT images.PRACTICAL IMPLICATIONS:Intentional replantation is recommended in mandibular first premolars with a mesiolingual lesion that cannot be accessed easily with endodontic microsurgery and after conservative retreatment has been performed.

Endodontic microsurgery is a predictable and successful procedure when using techniques that have been developed over the past several years. One of the steps during surgery involves curettage of the entire lesion. However, there are cases in which the lesion has advanced to invade anatomic structures like the nasal fossa, maxillary sinus, mandibular canal, neighboring vital teeth, or through and through to the palate. These lesions make endodontic microsurgery difficult for the operator to execute and have inherent risks to the patient. Selective curettage is a conservative approach to treat such cases by removing approximately 50%-70% of the granulomatous tissue while avoiding complications and damage to the neighboring structures. Three-dimensional cone-beam computed tomographic imaging, 2-dimensional periapical radiographs, and clinical follow-ups of the selective curettage lesions showed complete or incomplete (scar tissue) healing in all cases with no untoward results.

The goal of this paper is to explain the concepts and techniques of intentional replantation so as to encourage all practitioners to include this procedure in their armamentarium. We will seek to answer why this procedure is not done more frequently. The latest review of papers from the 1960s through 2017 shows a success rate approaching 89%. Other than newer root-end filling materials and transport media, the technique has not varied significantly. The CBCT has allowed for better imaging to help treatment plan the direction of extraction without fracturing the tooth. Future research may show easier ways or tools to more predictably remove a tooth atraumatically.

Introduction: The purpose of this randomized clinical trial was to evaluate healing after endodontic microsurgery (EMS) using mineral trioxide aggregate (MTA) versus EndoSequence root repair material (RRM; Brasseler, Savannah, GA) as root-end filling materials. Methods: Two hundred forty-three teeth with persistent or recurrent apical periodontitis were randomly assigned to either the MTA or RRM group. EMS was performed, and follow-up visits with clinical and radiographic investigation were scheduled at 6, 12, and 24 months with follow-up cone-beam computed tomographic (CBOT) imaging after 12 months. Results: One hundred twenty teeth with an average follow-up of 15 months were evaluated. The overall success rate was 93.3% for periapical (PA) evaluation and 85% for CBCT evaluation. The RRM group exhibited 92% and 84% success rates as assessed on PA and CBCT imaging, respectively. The MTA group exhibited 94.7% and 86% success rates as assessed on PA and CBCT imaging, respectively. No significant difference was observed between the 2 groups. Microsurgical classification, root canal filling quality, root-end filling material depth, and root fracture were found to be significant outcome predictors. Conclusions: EMS is a predictable procedure with successful outcome both 2-dimensional and 3-dimensional radiographic evaluation when RRM or MTA was used as the root-end filling material.

The field of endodontics has seen vast improvements in technology and techniques over the past several years. Perhaps the one area of endodontics that has improved the most is the way in which surgery is performed. With the use of state-of-the-art instruments, new and improved materials, and a surgical operating microscope, the gap has narrowed between biological concepts and the ability to achieve consistently successful clinical results. The practice of these techniques is now referred to as endodontic microsurgery.

Chapter 19 Guided Tissue Regeneration in Endodontic Microsurgery Garrett Guess, Garrett GuessSearch for more papers by this authorSamuel Kratchman, Samuel KratchmanSearch for more papers by this author Garrett Guess, Garrett GuessSearch for more papers by this authorSamuel Kratchman, Samuel KratchmanSearch for more papers by this author Syngcuk Kim DDS, PhD, MD, Syngcuk Kim DDS, PhD, MDSearch for more papers by this authorSamuel Kratchman DMD, Samuel Kratchman DMDSearch for more papers by this author Book Author(s):Syngcuk Kim DDS, PhD, MD, Syngcuk Kim DDS, PhD, MDSearch for more papers by this authorSamuel Kratchman DMD, Samuel Kratchman DMDSearch for more papers by this author First published: 25 August 2017 https://doi.org/10.1002/9781119412502.ch19 AboutPDFPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShareShare a linkShare onFacebookTwitterLinked InRedditWechat Abstract Guided tissue regenerative techniques involve the use of bone replacement grafting materials, cell-occlusive barriers or membranes, as well as bioactive host modulating agents used to maximize the body's healing potential to regenerate the body's lost tissues versus permitting them to repair. There are some types of cases encountered when performing endodontic microsurgery where consideration should be made as to whether utilizing guided tissue regenerative materials will make an impact. This chapter discusses all these cases. When a periodontal defect is encountered while performing endodontic microsurgery, based on clinical studies in endodontics and many in the field of periodontics, and guided tissue regenerative materials are implemented, a histologic, radiographic, and clinical benefit is realized. The benefit of using a membrane plus a graft in cases with periodontal problems is the potential to provide a more stable long-term periodontal condition. Microsurgery in Endodontics, First Edition RelatedInformation

Cone beam computed tomography (CBCT) has revolutionized dental imaging. It enables clinicians to easily view areas of interest in any plane and not be restricted by two-dimensional conventional radiography. CBCT has revolutionized dental imaging. The raw signal is converted into a single cylindrical or spherical digital volume described by its smallest subunit called the voxel, which is stacked in rows and columns for visualization. The data are projected in three planes: axial, sagittal, and coronal. A preoperative CBCT can help us to avoid putting the patient through an unnecessary procedure when an extraction is indicated. Once a surgical intervention is treatment planned, the software allows the clinician to make all necessary measurements, such as where to initiate the osteotomy if a bony fenestration is not present, utilizing root length and thickness of cortical bone. Similar applications of the CBCT apply for cases that necessitate repair of iatrogenic errors such as perforations and separated files.

Introduction: The objective of this article was to present a surgical treatment option for teeth with incomplete vertical root fracture in maxillary and mandibular posterior teeth. Methods: Four cases are presented in which 1 endodontically treated maxillary or mandibular molar had an incomplete vertical root fracture involving 1 of the roots. The tooth underwent a flap elevation procedure to visualize the pattern of bone loss and assess the extent of root fracture. The fracture line was eliminated by resecting the root in a beveled manner, after which root-end preparation and root-end filling were performed by using mineral trioxide aggregate. The osteotomy was covered with an absorbable collagen membrane. Cases were followed up for 8-24 months after surgery. Results: The procedure was shown to be predictable and successful in this series. Root length was preserved, and tooth extraction was avoided. Conclusions: The microsurgical treatment option for multirooted teeth with incomplete vertical root fracture resulted in long-term clinical success. (J Endod 2012;38:550-555)

From digital radiography units to office computer systems, there are several pieces of equipment that make up today's high-tech dental office. Recently, advances in dental imaging have allowed cone-beam computed tomography (CBCT), which is a form of 3-dimensional radiography, to gain increasing popularity as another major office component. In consideration of the current economic conditions, cost has become a definite obstacle for many practitioners. With several brands available, this technology has nonetheless generated considerable attention for use in presurgical treatment planning and diagnosis. However, is there enough evidence for its use in endodontics? This article aims to bring to light the many exciting features of CBCT, including its operation, impact, and feasibility in endodontics.

The authors report on data from a self-assessment questionnaire filled out by 199 patients undergoing periradicular microscopic surgery at two private endodontic offices and at graduate endodontic clinics of the University of Pennsylvania. Regression analysis was performed using pain and swelling as dependent variables and age, sex, type of teeth, location, periapical lesion, and remedication as independent variables. Pain and swelling were significantly related to females and younger patients (p < 0.05). The results supported Etodolac as a pre- and postoperative analgesic and use of antibiotics restricted to high-risk patients. Maximum pain and swelling were reported at night and day 1 of the surgery, respectively. Generally, swelling was more often reported than pain. Surgeries in anterior maxilla were related to more pain and swelling. A majority of the patients (67%) rated surgical endodontics more pleasant than expected and found it less painful (46%) or the same (38%) as nonsurgical treatment. The results also point out that patients in general have negative beliefs and limited knowledge about periradicular surgery.

Endodontic surgery has now evolved into endodontic microsurgery. By using state-of-the-art equipment, instruments and materials that match biological concepts with clinical practice, we believe that microsurgical approaches produce predictable outcomes in the healing of lesions of endodontic origin. In this review we attempted to provide the most current concepts, techniques, instruments and materials with the aim of demonstrating how far we have come. Our ultimate goal is to assertively teach the future generation of graduate students and also train our colleagues to incorporate these techniques and concepts into everyday practice.

As with any dental treatment, procedural mishaps can occur during root canal therapy. One such occurrence is the perforation of a root or pulpal floor. After a perforation occurs, the goals are to "sterilize" (decontaminate) the site and then seal the perforation. The material most widely used in endodontics to seal perforations is mineral trioxide aggregate (MTA). MTA us extremely biocompatible, and it has been shown historically that osteoidlike material grows right into MTA. The technique of one-step apexification offers an alternative to draw-out cases with several medicament-changing appointments that often result in a failed attempt at root-end closure. With the favorable histologic response of MTA, this material is the best current choice for this procedure. Completion of these cases in an effective and efficient way allows for permanent restorations to be done in a more timely manner, prolonging the longevity of these teeth.

With all the technology that has been introduced in endodontics, there are now several ways to instrument and obturate root canals. Practitioners often develop their own "hybrid" technique after sharing ideas with several colleagues. The purpose of this article is to describe a technique of obturation, hoping that others may incorporate some aspects into their own "hybrid" style.