Gingival recession following apical surgery in the esthetic zone: a clinical study with 70 cases

The present study evaluated gingival recession 1 year following apical surgery of 70 maxillary anterior teeth (central and lateral incisors, canines, and first premolars). A visual assessment of the mid-facial aspect of the gingival level and of papillary heights of treated teeth was carried out using photographs taken at pre-treatment and 1-year follow-up appointments. In addition, changes in the gingival margin (GM) and clinical attachment levels (CAL) were calculated with the use of clinical measurements, that is, pre-treatment and 1-year follow-up pocket probing depth and level of gingival margin. Changes in GM and CAL were then correlated with patient-, tooth-, and surgery-related parameters. The following parameters were found to significantly influence changes in GM and CAL over time: gingival biotype (P < 0.05), with thin biotype exhibiting more gingival recession than thick biotype; pre-treatment pocket probing depth (PPD) (P < 0.03), with cases of pre-treatment PPD < 2.5 mm demonstrating more attachment loss than cases of PPD > or = 2.5 mm; and type of incision (P < 0.01), with the submarginal incision showing considerably less gingival recession compared with the intrasulcular incision, papilla-base incision or papilla-saving incision. The visual assessment using pre-treatment and 1-year follow-up photographs did not demonstrate significant changes in gingival level or papillary height after apical surgery. In conclusion, gingival biotype, pre-treatment PPD, and type of incision may significantly influence changes in GM and CAL following apical surgery in maxillary anterior teeth.

Histology of periapical lesions obtained during apical surgery

The aim of this was to evaluate the histology of periapical lesions in teeth treated with periapical surgery. After root-end resection, the root tip was removed together with the periapical pathological tissue. Histologic sectioning was performed on calcified specimens embedded in methylmethacrylate (MMA) and on demineralized specimens embedded in LR White (Fluka, Buchs, Switzerland). The samples were evaluated with light and transmission electron microscopy (TEM). The histologic findings were classified into periapical abscesses, granulomas, or cystic lesions (true or pocket cysts). The final material comprised 70% granulomas, 23% cysts and 5% abscesses, 1% scar tissues, and 1% keratocysts. Six of 125 samples could not be used. The cystic lesions could not be subdivided into pocket or true cysts. All cysts had an epithelium-lined cavity, two of them with cilia-lined epithelium. These results show the high incidence of periapical granulomas among periapical lesions obtained during apical surgery. Periapical abscesses were a rare occasion. The histologic findings from samples obtained during apical surgery may differ from findings obtained by teeth extractions. A determination between pocket and true apical cysts is hardly possible when collecting samples by apical surgery.

Treatment decisions in 330 cases referred for apical surgery

INTRODUCTION Apical surgery is an important treatment option for teeth with postendodontic apical periodontitis. However, little information is available regarding treatment planning in cases referred for apical surgery. This study evaluated the decisions made in such cases and analyzed the variables influencing the decision-making process. METHODS The study retrospectively assessed clinical and radiographic data of 330 teeth that had been referred to a specialist in apical surgery with regard to the treatment decisions made in those teeth. The clinical and radiographic variables were divided into subcategories to analyze which factors influenced the decision-making process. RESULTS The treatment decisions included apical surgery (59.1%), tooth extraction (25.8%), no treatment (9.1%), and nonsurgical endodontic retreatment (6.1%). Variables that showed statistically significant differences comparing treatment decisions among subcategories included probing depth (P = .001), clinical attachment level (P = .0001), tooth mobility (P = .012), pain (P = .014), clinical signs (P = .0001), length (P = .041) and quality (P = .026) of the root canal filling, and size (P = .0001) and location (P = .0001) of the periapical lesion. CONCLUSIONS This study shows that apical surgery was the most frequently made treatment decision in teeth referred to a specialist in apical surgery, but every fourth tooth was considered nonretainable and was scheduled for extraction. The data showed that the most common variables that influenced the decision to extract teeth were teeth with an increased probing depth and tooth mobility and teeth presenting with lesions not located at the apex.

5-year results comparing mineral trioxide aggregate and adhesive resin composite for root-end sealing in apical surgery

INTRODUCTION Recent meta-analyses of the outcome of apical surgery using modern techniques including microsurgical principles and high-power magnification have yielded higher rates of healing. However, the information is mainly based on 1- to 2-year follow-up data. The present prospective study was designed to re-examine a large sample of teeth treated with apical surgery after 5 years. METHODS Patients were recalled 5 years after apical surgery, and treated teeth were classified as healed or not healed based on clinical and radiographic examination. (The latter was performed independently by 3 observers). Two different methods of root-end preparation and filling (primary study parameters) were to be compared (mineral trioxide aggregate [MTA] vs adhesive resin composite [COMP]) without randomization. RESULTS A total of 271 patients and teeth from a 1-year follow-up sample of 339 could be re-examined after 5 years (dropout rate = 20.1%). The overall rate of healed cases was 84.5% with a significant difference (P = .0003) when comparing MTA (92.5%) and COMP (76.6%). The evaluation of secondary study parameters yielded no significant difference for healing outcome when comparing subcategories (ie, sex, age, type of tooth treated, post/screw, type of surgery). CONCLUSIONS The results from this prospective nonrandomized clinical study with a 5-year follow-up of 271 teeth indicate that MTA exhibited a higher healing rate than COMP in the longitudinal prognosis of root-end sealing.

Comparison between Radiographic (2-dimensional and 3-dimensional) and Histologic Findings of Periapical Lesions Treated with Apical Surgery.

INTRODUCTION The aim of this study was to evaluate the concordance of 2- and 3-dimensional radiography and histopathology in the diagnosis of periapical lesions. METHODS Patients were consecutively enrolled in this study provided that preoperative periapical radiography (PR) and cone-beam computed tomographic imaging of the tooth to be treated with apical surgery were performed. The periapical lesional tissue was histologically analyzed by 2 blinded examiners. The final histologic diagnosis was compared with the radiographic assessments of 4 blinded observers. The initial study material included 62 teeth in the same number of patients. RESULTS Four lesions had to be excluded during processing, resulting in a final number of 58 evaluated cases (31 women and 27 men, mean age = 55 years). The final histologic diagnosis of the periapical lesions included 55 granulomas (94.8%) and 3 cysts (5.2%). Histologic analysis of the tissue samples from the apical lesions exhibited an almost perfect agreement between the 2 experienced investigators with an overall agreement of 94.83% (kappa = 0.8011). Radiographic assessment overestimated cysts by 28.4% (cone-beam computed tomographic imaging) and 20.7% (periapical radiography), respectively. Comparing the correlation of the radiographic diagnosis of 4 observers with the final histologic diagnosis, 2-dimensional (kappa = 0.104) and 3-dimensional imaging (kappa = 0.111) provided only minimum agreement. CONCLUSIONS To establish a final diagnosis of an apical radiolucency, the tissue specimen should be evaluated histologically and specified as a granuloma (with/without epithelium) or a cyst. Analysis of 2-dimensional and 3-dimensional radiographic images alike results only in a tentative diagnosis that should be confirmed with biopsy.

Evaluation of New Cone-beam Computed Tomographic Criteria for Radiographic Healing Evaluation after Apical Surgery: Assessment of Repeatability and Reproducibility.

INTRODUCTION Conventional 2-dimensional radiography uses defined criteria for outcome assessment of apical surgery. However, these radiographic healing criteria are not applicable for 3-dimensional radiography. The present study evaluated the repeatability and reproducibility of new cone-beam computed tomographic (CBCT)-based healing criteria for the judgment of periapical healing 1 year after apical surgery. METHODS CBCT scans taken 1 year after apical surgery (61 roots of 54 teeth in 54 patients, mean age = 54.4 years) were evaluated by 3 blinded and calibrated observers using 4 different indices. Reformatted buccolingual CBCT sections through the longitudinal axis of the treated roots were analyzed. Radiographic healing was assessed at the resection plane (R index), within the apical area (A index), of the cortical plate (C index), and regarding a combined apical-cortical area (B index). All readings were performed twice to calculate the intraobserver agreement (repeatability). Second-time readings were used for analyzing the interobserver agreement (reproducibility). Various statistical tests (Cohen, kappa, Fisher, and Spearman) were performed to measure the intra- and interobserver concurrence, the variability of score ratios, and the correlation of indices. RESULTS For all indices, the rates of identical first- and second-time scores were always higher than 80% (intraobserver Cohen κ values ranging from 0.793 to 0.963). The B index (94.0%) showed the highest intraobserver agreement. Regarding interobserver agreement, the highest rate was found for the B index (72.1%). The Fleiss' κ values for R and B indices exhibited substantial agreement (0.626 and 0.717, respectively), whereas the values for A and C indices showed moderate agreement (0.561 and 0.573, respectively). The Spearman correlation coefficients for R, A, C, and B indices all exhibited a moderate to very strong correlation with the highest correlation found between C and B indices (rs = 0.8069). CONCLUSIONS All indices showed an excellent intraobserver agreement (repeatability). With regard to interobserver agreement (reproducibility), the B index (healing of apical and cortical defects combined) and the R index (healing on the resection plane) showed substantial congruence and thus are to be recommended in future studies when using buccolingual CBCT sections for radiographic outcome assessment of apical surgery.

Assessment of the nonoperated root after apical surgery of the other root in mandibular molars: a 5-year follow-up study

INTRODUCTION If a surgical approach is chosen to treat a multirooted tooth affected by persistent periapical pathosis, usually only the affected roots are operated on. The present study assessed the periapical status of the nonoperated root 5 years after apical surgery of the other root in mandibular molars. METHODS Patients treated with apical surgery of mandibular molars with a follow-up of 5 years were selected. Patient-related and clinical parameters (sex, age, smoking, symptoms, and signs of infection) before surgery were recorded. Preoperative intraoral periapical radiographs and radiographs 5 years after surgery were examined. The following data were collected: tooth, operated root, type and quality of the coronal restoration, marginal bone level, length and homogeneity of the root canal filling, presence of a post/screw, periapical index (PAI) of each root, and radiographic healing of the operated root. The presence of apical pathosis of the nonoperated root was analyzed statistically in relation to the recorded variables. RESULTS Thirty-seven patients fulfilled the inclusion criteria. Signs of periapical pathosis in the nonoperated root 5 years after surgery (PAI ≥ 3) could be observed in only 3 cases (8.1%). Therefore, statistical analysis in relation to the variables was not possible. The PAI of the nonoperated root before surgery had a weak correlation with signs of apical pathosis 5 years after surgery. CONCLUSIONS Nonoperated roots rarely developed signs of new apical pathosis 5 years after apical surgery of the other root in mandibular molars. It appears reasonable to resect and fill only roots with a radiographically evident periapical lesion.

Five-year longitudinal assessment of the prognosis of apical microsurgery

Apical surgery is an important treatment option for teeth with post-treatment apical periodontitis. Knowledge of the long-term prognosis is necessary when weighing apical surgery against alternative treatments. This study assessed the 5-year outcome of apical surgery and its predictors in a cohort for which the 1-year outcome was previously reported.

[Periapical surgery with histologic examination of the periapical lesion. A case report]

Periapical surgery is required when periradicular pathosis associated with endodontically treated teeth cannot be resolved by nonsurgical root canal therapy (retreatment), or when retreatment was unsuccessful, not feasible or contraindicated. Endodontic failures can occur when irritants remain within the confines of the root canal, or when an extraradicular infection cannot be eradicated by orthograde root canal treatment. Foreign-body reponses towards filling materials, towards cholesterol crystals or radicular cysts might prevent complete periapical healing. Following enhanced microsurgical techniques in the last years the success rates of apical surgery have improved considerably. The aim of the current case report is to describe the therapeutical approach to a persistent periapical lesion and its histologic examination.

Changes of Root Length and Root-to-Crown Ratio after Apical Surgery: An Analysis by Using Cone-beam Computed Tomography

INTRODUCTION Apical surgery is an important treatment option for teeth with post-treatment periodontitis. Although apical surgery involves root-end resection, no morphometric data are yet available about root-end resection and its impact on the root-to-crown ratio (RCR). The present study assessed the length of apicectomy and calculated the loss of root length and changes of RCR after apical surgery. METHODS In a prospective clinical study, cone-beam computed tomography scans were taken preoperatively and postoperatively. From these images, the crown and root lengths of 61 roots (54 teeth in 47 patients) were measured before and after apical surgery. Data were collected relative to the cementoenamel junction (CEJ) as well as to the crestal bone level (CBL). One observer took all measurements twice (to calculate the intraobserver variability), and the means were used for further analysis. The following parameters were assessed for all treated teeth as well as for specific tooth groups: length of root-end resection and percentage change of root length, preoperative and postoperative RCRs, and percentage change of RCR after apical surgery. RESULTS The mean length of root-end resection was 3.58 ± 1.43 mm (relative to the CBL). This amounted to a loss of 33.2% of clinical and 26% of anatomic root length. There was an overall significant difference between the tooth groups (P < .05). There was also a statistically significant difference comparing mandibular and maxillary teeth (P < .05), but not for incisors/canines versus premolars/molars (P = .125). The mean preoperative and postoperative RCRs (relative to CEJ) were 1.83 and 1.35, respectively (P < .001). With regard to the CBL reference, the mean preoperative and postoperative RCRs were 1.08 and 0.71 (CBL), respectively (P < .001). The calculated changes of RCR after apical surgery were 24.8% relative to CEJ and 33.3% relative to CBL (P < .001). Across the different tooth groups, the mean RCR was not significantly different (P = .244 for CEJ and 0.114 for CBL). CONCLUSIONS This CBCT-based study demonstrated that the RCR is significantly changed after root-end resection in apical surgery irrespective of the clinical (CBL) or anatomic (CEJ) reference levels. The lowest, and thus clinically most critical, postoperative RCR was observed in maxillary incisors. Future clinical studies need to show the impact of resection length and RCR changes on the outcome of apical surgery.

Evaluation of Ultrasonic and ErCr:YSGG Laser Retrograde Cavity Preparation

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Comparative study of MTA and other materials in retrofilling of pulpless dogs' teeth

This in vivo study compared the effect of mineral trioxide aggregate (MTA), IRM, Super EBA and ZOE in a puttylike consistency, used as retrofilling materials, in the healing process of periapical tissue of pulpless dogs' teeth submitted to a conventional retrofilling technique. Twenty-four premolars obtained from three dogs were used. At the first intervention, the animals were anesthetized, coronal access was obtained and pulpectomy was done. Root canals were kept open to the oral environment for 180 days to induce the formation of apical lesions. After surgical removal of the lesions with curettes, 2 mm of the apical root was cut out perpendicular to the long axis of the teeth, and root-end cavities were shaped with a low-speed round bur. The bone cavities were irrigated and dried, and the root-end cavities were filled with MTA, IRM, Super EBA and ZOE in a puttylike consistency. The bone cavities were passively filled with blood and flaps were sutured. The coronal access openings were cleaned and double-sealed with ZOE and amalgam. After 180 days, the animals were killed by anesthetic overdose, maxilla and mandible were removed and the pieces were processed for histomorphologic analysis. Data were evaluated blindly on the basis of several histopathologic events and the scores obtained were analyzed statistically using the Kruskal Wallis test. No significant differences were observed among MTA, Super EBA and IRM (p>0.05). However, ZOE had a significantly more negative influence on the apical healing (p<0.05). In conclusion, MTA, Super EBA and IRM had similar histopathologic effects among each other and better performance than ZOE used in a puttylike consistency. Furthermore, only MTA stimulated hard tissue deposition in direct contact with the retrofilling material, even when it was inserted under critical conditions.

The challenges of treating a fused tooth

This paper describes and discusses the multidisciplinary treatment involving a permanent maxillary lateral incisor fused to a supernumerary tooth, both presenting pulp necrosis and periapical lesion. A 15-year-old male patient sought treatment complaining of pain, swelling and mobility on the maxillary right lateral incisor. After clinical and radiographic examination, root canal preparation was performed according to the crown-down technique and a calcium hydroxide dressing was placed for 15 days. The patient returned and the definitive endodontic filling was done with thermomechanical compaction of gutta-percha and sealer. After 18 months, clinical and radiographic examinations were carried out and no pain or swelling was reported. Two years after endodontic treatment, the patient returned for periodontal and cosmetic treatments. Nine months later, a cone-beam computed tomography (CBCT) revealed that the previously detected periodontal defect and periapical lesion were persistent. Apical endodontic surgery was indicated. The supernumerary tooth was removed, the communicating distal surface was filled and the surgical site received bioactive glass and demineralized bovine organic bone. The pathological tissue was submitted to histopathological examination and the diagnosis was periapical cyst. One year after the apical endodontic surgery, CBCT showed bone formation at maxillary lateral incisor apical area. Two years after the surgery, the restoration was replaced due to aesthetic reasons and periapical radiograph showed success after 5 years of treatment. A correct diagnosis and establishment of an adequate treatment plan resulted in a successful management of the case.

Combined therapy with mineral trioxide aggregate, and guided tissue regeneration for a large radicular cyst: A 13-year follow-up

Biomaterials such as membrane barriers and/or bone grafts are often used to enhance periapical new bone formation. A combination of apical surgery and these biomaterials is one of the latest treatment options for avoiding tooth extraction. In case of periapical lesions, guided tissue regeneration (GTR) is attempted to improve the self-regenerative healing process by excluding undesired proliferation of the gingival connective tissue or migration of the oral epithelial cells into osseous defects. In many cases, GTR is necessary for achieving periodontal tissue healing. This report describes the healing process after surgery in a challenging case with a long-term followup. In this case report, endodontic surgery was followed by retrograde sealing with mineral trioxide aggregate (MTA) in the maxillary right central incisor and left lateral incisor. Apicectomy was performed in the maxillary left central incisor and a 1-mm filling was removed. The bone defect was filled with an anorganic bone graft and covered with a decalcified cortical osseous membrane. No intraoperative or postoperative complications were observed. After 13 years of follow-up, the patient showed no clinical signs or symptoms associated with the lesion and radiographic examination showed progressive resolution of radiolucency. In conclusion, the combination of apical surgery and regenerative techniques can successfully help the treatment of periapical lesions of endodontic origin and is suitable for the management of challenging cases.