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Journal of Oral Science & Rehabilitation No. 3, 2017

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 The diagnostic value of pretreatment radio- graphs depends on how well they reflect the histology of AP. Studies that have investigated the correlation between histological appearance and radiographic manifestations have found that the absence of radiographic signs does not pre- clude apical inflammation, and the radiographic appearance is always smaller than the histolog- ical extent of the lesion.20–23 Radiographic signs pathognomonic of AP include radiolucent changes in periradicular trabecular pattern and altered shape and width of the periodontal lig- ament (PDL) space.3, 7, 11, 13 However, periapical radiographs and panoramic imaging have inher- ent limitations, such as superimposition and distortion of important structures that com- monly mask lesions.17, 19 In addition, lesions in cancellous bone cannot be consistently detected with these radiographic techniques.5 Therefore, in some cases, extensive bone resorption may be present even when there is no radiographic evidence of it.5 The appearance of the periapical tissue on a radiograph is influenced by the super- imposition of anatomical structures and the variable nature of the overlying bone density and texture.12, 18 The limitations of periapical radiog- raphy have led to significant interest in CBCT. Currently, the use of CBCT imaging has made it possible to visualize the related anatomical structures in 3-D with higher resolution. This has improved the overall diagnostic efficacy and made early diagnosis possible for some specific clinical situations.22, 27 In endodontic practice, CBCT imaging with limited fields of view has been suggested for diagnosis in patients with contradictory or nonspecific clinical signs and symptoms.27 Postsurgical excisional wound healing after periradicular surgery entails dentoalveolar heal- ing (i.e., reestablishment of an apical attachment apparatus) and alveolar healing (i.e., osseous repair of trabecular and cortical bone).2 Cemen- tum deposition on the root end is considered the critical step in dentoalveolar wound healing.2 Consequently, creating an environment condu- cive to cementogenesis should enhance the heal- ing process after surgical endodontic treatment. In periodontal surgery, dentin demineraliza- tion leads to enhanced connective tissue attach- ment through splicing of exposed dentinal col- lagen with new collagen fibers produced during wound healing and early deposition of cemen- tum on the dentinal surfaces.9 Demineralizing the root surface with citric acid has been shown to increase cemento genesis and promote periradicular wound healing by exposing the collagen matrix, which stimulates fibroblast attachment and growth.9 The lower pH of citric acid may induce initially a more intense inflammatory response compared with saline. This may inhibit the healing process as measured by new bone formation. As healing progresses, the potential benefits of the anti- collagenase activity may allow for more rapid collagen formation and ultimately allow more rapid new bone formation.10 The irrigation is conducted with EndoVac, as the EndoVac System safely delivers irrigants to the apical terminus of root canals.21 The device consists of a delivery/evacuation tip attached to a syringe of irrigant and the high-volume suction of the dental chair. Using a combination of a macro- or microcannula attached to the suction device, the irrigant introduced into the pulp chamber is pulled by negative pressure down the canal into the tip of the cannula and removed through the suction hose, thus avoiding any extrusion of the irrigant outside the root canal area, since the PDL barrier is lost then and the use of conventional irrigating methods could result in pushing the chemicals into the exposed surgical site.21 Case descriptions C a s e 1 The patient was referred to the clinic with a swelling in the palatal area of the maxillary lat- eral incisor (Figs. 1a & b). Axial slices of CBCT cans showed substantial bone loss at the apical level of the maxillary lateral incisor (Fig. 1c) and at the level of the two maxillary central incisors (Fig. 1d). After administration of the anesthesia, a syringe was inserted into the palatal mucosa and a large amount of pus was aspirated. After following the procedural steps previously described and the removal of the cystic reaction, a long section of the root canals was exposed, especially that of the lateral and central incisors. Immediate postoperative radiographs were taken (Figs. 1e & f), and then 1-year follow-up radiographs (Figs. 1g & h). The 1-year follow-up images showed the formation of new bone around the teeth and of a new PDL. The 5-year follow-up radiograph (Fig. 1i) indicated an intact PDL, a smaller fibrous area and no signs of exter- nal or internal resorption. 20 Volume 3 | Issue 3/2017 Journal of Oral Science & Rehabilitation

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