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N o a p i c e c t o m y i n e n d o d o n t i c s u r g e r y Introduction Surgical endodontic treatment is an option for teeth with apical periodontitis and may be indi- cated for teeth previously submitted to unsuc- cessful endodontic treatment and teeth with a strong possibility of failure by the nonsurgical approach.6, 14, 29 This procedure usually consists of several steps, including retrograde obturation, which is performed after root sectioning and preparation of a cavity in the root canal.6 Furthermore, the presence of apical true cysts requires surgical treatment as well, as these cysts are less likely to heal by conventional root canal therapy because they are self- sustaining and no longer dependent on the pres- ence or absence of root canal infection.8, 26, 24 Accordingly, surgical intervention of apical true cysts is necessary.15, 20, 23, 25 This technique can be performed when conducting a root canal treatment or a retreatment of the root canal system, combined with a surgical approach for the removal of the cyst. If access to the root canal system is not possible, a conventional api- cectomy can be performed. The limitations of periapical radiography have led to significant interest in cone beam computed tomography (CBCT) in endodontic applications. It seems that number of CBCT scans taken every year is increasing as aware- ness increases, resolution increases and costs decrease.28 With the use of CBCT, cystic lesions are easily identified. In this article, we will describe a new approach in surgical endodontics that focuses on preserving the integrity of the apical part of the root. We will illustrate this approach with a series of cases showing the preoperative condi- tion and postoperative healing. Materials and methods Once there is a positive diagnosis of an apical cyst with CBCT, the patient is informed of the situation and the different steps of the treat- ment. The procedure is performed under local anesthesia with the use of articaine with 1:100,000 epinephrine infiltrated under the peri- osteum. We then proceed by isolating the tooth or teeth with a rubber dam and then shaping and cleaning the root canal system. The irrigation is conducted with the EndoVac negative-pressure device (SybronEndo, Orange, Ca., U.S.).21 Once the working length has been determined elec- tronically, the irrigation cannula can be placed at the working length.21 After the irrigation is completed, a temporary filling is placed in the access cavity and the rubber dam removed. The obturation of the canal is deferred, as the canal cannot be properly dried at this stage. The following step is performing the surgical part, first by raising a flap and identifying the cyst. The cystic area is carefully spooned out while preserving the cementum and ligaments that are attached to the root surface. The exposed part of the root is rinsed with normal saline followed by the application of citric acid at a neutral pH with a microbrush on the root surface. After the latter step, the area is rinsed abundantly again with sterile water or normal saline. As the flap is temporarily put back in place, the tooth or teeth are isolated again with a rubber dam, the temporary filling is removed and a full sequence of irrigation with the use of EndoVac is conducted again. The master cone is adjusted, and full obturation of the root canal system is performed using warm vertical obtu- ration. A temporary filling material is then placed in the access cavity and the isolating dam removed. The final step consists of raising the flap again and checking whether any large extru- sion of the obturation material occurred that would need to be removed. The sutures are placed, and postoperative medication is pre- scribed. Discussion Apical periodontitis (AP) is an inflammatory or immune response in the apical periodontium that often results from intracanal microorgan- isms. The resulting apical bone resorption is a defense mechanism that prevents the spread of infection and appears radiolucent on radio- graphs.23, 16 Because AP is usually asymptomatic, it is frequently only detected during routine radiographic examination.4 In this sense, radi- ography is essential for the successful and timely diagnosis of AP and historically has been limited to periapical and panoramic radiographs.1 Furthermore, radiographic imaging is essential in all stages of endodontics, from diagnosis through long-term assessment of healing out- comes. In conjunction with symptoms, outcome is assessed by comparison of preoperative and immediate postoperative radiographs, with sub- sequent radiographs taken at recall appoint- ments.12, 18 Journal of Oral Science & Rehabilitation Volume 3 | Issue 3/2017 19