The use of regenerative techniques in apical surgery: A literature review

AbstractApical surgery has become a standard of care for tooth maintenance if conventional endodontic retreatment is not possible or associated with risks. However, in certain situations, the outcome of apical surgery may be compromised due to the extent or location of the periapical or periradicular lesions. The present review article including clinical and experimental studies reports and discusses the outcome of regenerative techniques (RT) in conjunction with apical surgery, with regard to the type of periradicular lesions:Apical lesionsThe majority of studies have shown no benefit for healing in test sites treated with RT compared to control sites treated without RT. The use of a radio-opaque bone filler/substitute may even compound the radiographic interpretation of periapical healing. Currently, the use of RT for lesions <10mm limited to the apical area is not warranted.Through-and-through lesionsAll reviewed studies demonstrated a better outcome for test sites with RT compared to the control sites without RT; hence the use of RT for treatment of tunnel lesions in apical surgery is recommended.Apico-marginal lesionsAll clinical studies assessed cohorts without controls, and, therefore, no firm conclusion about the benefit of RT for treatment of apico-marginal lesions in conjunction with apical surgery can be drawn. However, the experimental animal studies have shown that healing of teeth with apico-marginal lesions appears to benefit from RT

Neurosensory Disturbances After Apical Surgery of Mandibular Premolars and Molars: A Retrospective Analysis and Case-Control Study.

OBJECTIVE Apical surgery is an intervention to treat teeth with persistent or recurrent endodontic infection. The proximity of the mental foramen and mandibular canal may pose a risk of altered sensation when performing surgical interventions in the posterior mandible. The objective of this study was to determine the rate of neurosensory disturbances after apical surgery of mandibular premolars and molars. The secondary objective was to evaluate whether the occurrence of altered sensation correlated with the distances from the apex or the periapical lesion to the relevant anatomical structures. METHODS The charts of patients treated from September 1999 to December 2015 were retrospectively evaluated if an apical surgery had been performed in mandibular premolars or molars, and a minimum period of 1-year follow-up was documented. Patients with trauma or other surgical interventions in the same hemimandible were excluded. Cases with postsurgical altered sensation were defined as the test group. From the pool of unaffected cases, patients were selected to serve as controls. Two- or three-dimensional radiographs of test and control cases were assessed with regard to the shortest distances from the root apices/lesions to the mental foramen or mandibular canal. RESULTS The study population included 243 patients with 249 apical surgeries, of which 12.9% led to postoperative neurosensory disturbances. Sensation returned to normal within 22 days on average. The most frequent findings were hyperesthesia or paresthesia. With regard to the treated type of tooth, second premolars resulted more frequently (22.6%) in altered sensation than the other teeth (11.2 to 13.0%; p=0.310). There were no significant differences when comparing test and control cases regarding the measured distances in radiographs from the apex/lesion to the relevant anatomical structures. CONCLUSION Altered sensation may typically occur following apical surgery in posterior mandibular teeth. However, in all cases of the present study, skin sensitivity in the lip/chin region returned to normal. The clinician must be particularly careful when performing apical surgery of second premolars due to the proximity of the mental foramen

Horizontal Ridge Augmentation in Conjunction with or Prior to Implant Placement in the Anterior Maxilla: A Systematic Review

PURPOSE To systematically review clinical studies examining the survival and success rates of implants in horizontal ridge augmentation, either prior to or in conjunction with implant placement in the anterior maxilla. MATERIALS AND METHODS A literature search was undertaken up to September 2012 including clinical studies in English with ≥ 10 consecutively treated patients and a mean follow-up of at least 12 months. Two reviewers screened the pertinent articles and extracted the data. Key words focused on the outcome parameters (implant success, implant survival, horizontal bone gain, and intra- and postoperative complications) in studies utilizing either a simultaneous approach (ridge augmentation performed at the time of implant placement) or a staged approach (ridge augmentation performed prior to implant placement) were analyzed. RESULTS A total of 13 studies met the inclusion criteria, with 2 studies in the simultaneous group and 11 studies in the staged group. In the simultaneous group, survival rates of implants were 100% in both studies, with one study also reporting a 100% implant success rate. No data on horizontal bone gain were available. In the staged group, success rates of implants placed in horizontally augmented ridges ranged from 96.8% to 100% (two studies), and survival rates ranged from 93.5% to 100% (five studies). However, follow-up periods differed widely (up to 4.1 years). Mean horizontal bone gain determined at reentry (implant placement) ranged from 3.4 to 5.0 mm with large overall variations (0 to 9.8 mm, five studies). Intraoperative complications were not reported. Postsurgical complications included mainly mucosal dehiscences (five studies), and, occasionally, complete failures of block grafts were described in one study. CONCLUSIONS Staged and simultaneous augmentation procedures in the anterior maxilla are both associated with high implant success and survival rates. The level of evidence, however, is better for the staged approach than for the simultaneous one

The resection angle in apical surgery: a CBCT assessment.

OBJECTIVES The primary objective of the present radiographic study was to analyse the resection angle in apical surgery and its correlation with treatment outcome, type of treated tooth, surgical depth and level of root-end filling. MATERIALS AND METHODS In the context of a prospective clinical study, cone beam computed tomography (CBCT) scans were taken before and 1 year after apical surgery to measure the angle of the resection plane relative to the longitudinal axis of the root. Further, the surgical depth (distance from the buccal cortex to the most lingual/palatal point of the resection plane) as well as the level of the root-end filling relative to the most coronal point of the cut root face was determined. Treated teeth were categorized into four groups (maxillary and mandibular anterior and posterior teeth). The final material comprised 62 treated roots in 55 teeth. RESULTS The mean calculated resection angle of all roots was 17.7° ± 11.4° (range -9.6° to 43.4°). Anterior maxillary roots presented the highest mean angle (25.8° ± 10.3°) that was significantly different from the mean angle in posterior maxillary roots (10.7° ± 9.4°; p 20°), however without reaching statistical significance (p = 0.0905). Angles did not correlate either with the surgical depth or with the retrofilling length. CONCLUSIONS Statistically significant differences were observed comparing resection angles of different tooth groups. However, the angle had no significant effect on treatment outcome. CLINICAL RELEVANCE Contrary to common belief, the resection angle in maxillary anterior teeth was greater than in the other teeth. The surgeon is advised to pay attention to the resection angle when bevelling maxillary anterior teeth in apical surgery

Influence of hemostatic agents upon the outcome of periapical surgery: dressings with anesthetic and vasoconstrictor or aluminum chloride

Objective: To evaluate the effects of different hemostatic agents upon the outcome of periapical surgery. Design: A retrospective study was made of patients subjected to periapical surgery between 2006-2009 with the ultrasound technique and using MTA as retrograde filler material. We included patients with a minimum follow- up of 12 months, divided into two groups according to the hemostatic agent used: A) dressings impregnated in anesthetic solution with adrenalin; or B) aluminum chloride paste (Expasyl TM). Radiological controls were made after 6 and 12 months, and on the last visit. The global evolution scale proposed by von Arx and Kurt (1999) was used to establish the outcome of periapical surgery. Results: A total of 96 patients (42 males and 54 females) with a mean age of 40.7 years were included. There were 50 patients in the aluminum chloride group and 46 patients in the anesthetic solution with vasoconstrictor group. No significant differences were observed between the two groups in terms of outcome after 12 months - the suc - cess rate being 58.6% and 61.7% in the anesthetic solution with vasoconstrictor and aluminum chloride groups, respectively (p>0.05). Conclusion: The outcome after 12 months of follow-up was better in the aluminum chloride group than in the anesthetic solution with vasoconstrictor group, though the difference was not significant

Assessment of bone channels other than the nasopalatine canal in the anterior maxilla using limited cone beam computed tomography

Purpose: The anterior maxilla, sometimes also called premaxilla, is an area frequently requiring surgical interventions. The objective of this observational study was to identify and assess accessory bone channels other than the nasopalatine canal in the anterior maxilla using limited cone beam computed tomography (CBCT). Methods: A total of 176 cases fulfilled the inclusion criteria comprising region of interest, quality of CBCT image, and absence of pathologic lesions or retained teeth. Any bone canal with a minimum diameter of 1.00mm other than the nasopalatine canal was analyzed regarding size, location, and course, as well as patient gender and age. Results: A total of 67 accessory canals ≥1.00mm were found in 49 patients (27.8%). A higher frequency of accessory canals was observed in males (33.0%) than in females (22.7%) (p=0.130). Accessory canals occurred more frequently in older rather than younger patients (p=0.115). The mean diameter of accessory canals was 1.31±0.26mm (range 1.01-2.13mm). Gender and age did not significantly influence the diameter. Accessory canals were found palatal to all anterior teeth, but most frequently palatal to the central incisors. In 56.7%, the accessory canals curved superolaterally and communicated with the ipsilateral alveolar extension of the canalis sinuosus. Conclusions: The study confirms the presence of bone channels within the anterior maxilla other than the nasopalatine canal. More than half of these accessory bone canals communicated with the canalis sinuosus. From a clinical perspective, studies are needed to determine the content of these accessory canal

Long-term effectiveness of 6 mm micro-rough implants in various indications: A 4.6- to 18.2-year retrospective study.

OBJECTIVES To evaluate the long-term effectiveness of 6 mm implants in various indications with a micro-rough surface after 4.6-18.2 years in function and to assess key factors associated with implant survival, success, and biologic/technical complications. MATERIALS AND METHODS Fifty-five patients with seventy-four 6 mm implants placed from 2000 to 2013 attended the re-examination assessing well-established clinical and radiographic parameters, biologic and prosthetic complications, and patient-reported outcome measures. RESULTS Five implants were lost after a mean follow-up period of 9.1 years resulting in a survival rate of 93.2%. All losses occurred in free-end situations in the mandible. Smoking habit significantly reduced implant survival (hazard ratio 36.25). Two implants exhibited a history of peri-implantitis, and one implant showed progressive marginal bone loss (MBL) resulting in a success rate of 89.2%. The mean MBL amounted to 0.029 mm. Increased MBL was found for implants placed in the maxilla (0.057 mm) and for implants with a diameter of 4.1 mm (0.043 mm). Soft tissue thickness (1.39 mm) and width of keratinized mucosa (1.91 mm) had no effect on MBL. Patient-reported outcome measures showed high satisfaction (mean VAS scores 88%) and high quality of life (mean OHIP-G14 score 2.2). CONCLUSION The present study demonstrated survival and success rates of 93.2% and 89.2% for 6 mm implants used in various indications. A factor leading to higher implant failure was smoking, whereas modulating factors increasing annual MBL included implants placed in the maxilla and implants with a diameter of 4.1 mm compared to 4.8 mm

Evaluation of healing criteria for success after periapical surgery

Introduction: In periapical surgery, the absence of standardization between different studies makes it difficult to compare the outcomes. Objective: To compare the healing classification of different authors and evaluate the prognostic criteria of periapical surgery at 12 months. Material and methods: 278 patients (101 men and 177 women) with a mean age of 38.1 years (range 11 to 77) treated with periapical surgery using the ultrasound technique and a 2.6x magnifying glass, and silver amalgam as root-end filling material were included in the study. Evolution was analyzed using the clinical criteria of Mikkonen et al., 1983; radiographic criteria of Rud et al., 1972; the overall combined clinical and radiographic criteria of von Arx and Kurt, 1999; and the Friedman (2005) concept of functional tooth at 12 months of surgery. Results: After 12 months, 87.2% clinical success was obtained according to the Mikkonen et al., 1983 criteria; 73.9% complete radiographic healing using Rud et al. criteria; 62.1% overall success, following the clinical and radiographic parameters of von Arx and Kurt, and 91.9% of teeth were functional. The von Arx and Kurt criteria was found to be the most reliable. Conclusion: Overall evolution according to von Arx and Kurt agreed most closely with the other scales

Pain and swelling after periapical surgery related to the hemostatic agent used : anesthetic solution with vasoconstrictor or aluminum chloride

Objective: To assess pain and swelling in the first 7 days after periapical surgery and their relationship with the agent used for bleeding control. Study Design: A prospective study was conducted between October 2006 and March 2009. Patients subjected to root surgery, who completed the questionnaire and who consented to the postoperative instructions were included in the study. The subjects were divided into two groups according to the hemostatic agent used: A) gauze impregnated with anesthetic solution with vasoconstrictor; or B) aluminum chloride. The patients were administered a questionnaire, and were asked to record the severity of their pain and swelling on a plain horizontal visual analog scale (VAS). Data were recorded by the patients on the first 7 postoperative days. In addition, the patients were asked to record analgesic consumption. Results: A total of 76 questionnaires (34 in group A and 42 in group B) were taken to be correctly completed. Pain was reported to be most intense two hours after surgery. At this point 52.6% of the patients had no pain. Seventy-five percent of the patients consumed analgesics in the first 24 hours. There were no significant differences between the two groups in terms of the intensity of pain or in the consumption of analgesics. Swelling reached its maximum peak on the second day; at this point, 60.6% of the patients suffered mild or moderate swelling. The Expasyl? group showed significantly greater swelling than the gauzes group. Conclusion: The type of hemostatic agent used did not influence either the degree of pain or the need for analgesia among the patients in this study. However, the patients belonging to the Expasyl? group suffered greater swelling than the patients treated with gauzes impregnated with anesthetic solution with vasoconstrictor

Anatomical variations of the ethmoid sinuses and their association with health or pathology of the ethmoid and maxillary sinuses in a Southern Chinese population: An analysis using cone-beam computed tomography.

Purpose The aim of this study was to evaluate the prevalence of clinically relevant anatomical variations of the ethmoid sinuses and their potential association with ethmoid and maxillary sinus pathologies on cone-beam computed tomography (CBCT) scans. Additionally, potential associations with different sides and demographic factors, including age and sex, were evaluated. Materials and Methods In total, 273 CBCT scans with complete ethmoid and maxillary sinuses were analyzed to determine the prevalence of Agger nasi cell, supraorbital ethmoid cell, Haller cell, Onodi cell, and ethmomaxillary sinus. In addition, the health or pathology of the ethmoid and maxillary sinuses was also recorded to assess correlations with the aforementioned variations. Results The prevalence of Agger nasi cell was found to be the highest (95.6%) in this study, followed by Onodi cell (60.4%), Haller cell (29.3%), and supraorbital ethmoid cell (19.4%). Ethmomaxillary sinus was the least common finding (16.5%). Males and persons above 61 years of age had a significantly higher frequency of supraorbital ethmoid cell and Onodi cell, respectively. However, no significant relationships were noted between anatomical variations of the ethmoid sinus and pathologies of the ethmoid or maxillary sinus. Conclusion There was a high prevalence of ethmoid sinus variations in this Southern Chinese population. The prevalence of Agger nasi cell and Onodi cell was higher than that of other anatomical variations of the ethmoid sinuses. Anatomical variations of the ethmoid sinuses were not associated with ethmoid or maxillary sinus pathologies in this patient cohort