Various factors make endodontic microsurgery an essential complementary treatment for the healing of periradicular infections, thereby extending the lifespan of natural teeth and significantly enhancing patients’ quality of life. This approach often presents significant challenges for clinicians. However, with meticulous planning, these challenges can be effectively managed, reducing risks and increasing the success rates of tooth survival procedures. This lecture will explore the latest methods available to overcome the diverse clinical challenges encountered in endodontic microsurgery.

The necrotic tooth with “Open apex” is a condition which represents a treatment challenge in endodontics. It is a    clinical situation which may be the consequence of:  1) trauma which has caused the interruption of the development of the pulpal-dentinal complex in  immature teeth;  2) trauma which leaves the teeth in an immature stage, but is  discovered in the adult age; 3)  complex anatomies such as “dens in dente” 4) Resorptive defects that create irregularly opened apices.  Current treatment options and techniques include traditional apexification, MTA apexification, and the latest trends that are represented by the so-called regenerative/reparative procedures.

The different options will be discussed in the background of clinical experience and literature.

Learning Objectives

1. At conclusion participants should be able to consider “classic apexification” as a good and predictable treatment standard and the best up to date  protocols to use it
2. At conclusion participants should be able to recognize the use of “MTA/bioactive cements pre-formed apical barrier” as an alternative treatment  which is becoming more predictable after  15 years of  clinical experience, and  the best protocols on how to use it
3. At conclusion participants should be able to apply open apex treatment to resorbed teeth
4. At conclusion participants should be able mix the available techniques to apply them to unusual clinical situations
5. At conclusion participants should be able to consider the possibility to attempt “ regenerative procedures”  in  immature teeth

AL ALLOYS:  What is the best choice in daily practice.

Root canal shaping has always been one of the fundamental moments of endodontic therapy, for years the use of nickel titanium rotary instruments has enormously facilitated this phase and the continuous updating of the alloys has partly modified the methods of use of the instruments themselves. The report will analyze all the clinical aspects that guide us in the choice of instruments according to the different anatomical situations to be faced.

Lesions are the result of the evolution of an Apical Periodontitis and are due to a bacterial proliferation. But when a large periapical lesion is diagnosed on the X-ray, most of the time, the first idea is to ask how to remove it and then who will be able to do it surgically: the practitioner, the oral surgeon or possibly the endodontist.

In fact, faced with this situation, the first step is a precise diagnosis to determine the origin of the lesion and ensure that it is a lesion of endodontic origin, in order to avoid treating endodontically vital teeth or performing unnecessary surgery.

Different tests will be necessary (vitality tests, CBCT, and clinical examination) and the analysis of the results and their comparison with the patient’s perception will allow us to make this diagnosis and to determine our therapeutic choice between an endodontic or surgical treatment or both.

Throughout this presentation, our experiment, as a clinician, will allow the participants through many clinical cases, to learn to diagnose and treat large periapical lesions.

Root resorption is a pathological process involving the destruction of tooth root structures, often triggered by trauma, orthodontic forces, or inflammation. This condition poses significant challenges in diagnosis and treatment due to its complex and variable nature. Recent advancements, particularly in imaging technologies like cone-beam computed tomography (CBCT), have enhanced early detection and assessment of root resorption. A deeper understanding of the differential diagnosis between all the types of root resorption is paving the way for more effective, individualized management strategies. Further research is necessary to refine these approaches and improve patient outcomes.

Composite materials are mixtures of organic resins and inorganic filler particles, interconnected by an interfacial bonding agent. Composite materials can also be defined as a combination of two or more chemically different materials with a clear boundary between the components, which is characterised by properties better than those of its individual components. The key component is a mixture of different monomers that convert to a cross-linked polymer matrix during the process of polymerisation. In addition to monomers, other components are necessary to attain the desired properties of the composite material, namely fillers, an interfacial bonding agent, and polymerisation initiators. All the components of composites have been changed, developed and improved to get the composites we have today. As composite materials have found applications in all branches of contemporary dental medicine, daily work in modern dental practice is unthinkable without this material group. Composite materials are used for many indications, ranging from reconstructions of carious defects, traumas, morphological and aesthetic abnormalities, discolourations in permanent and deciduous dentition, as cavity coatings, pit and fissure sealants, inlays, onlays, overlays, crowns, luting materials for indirect restorations and intracanal posts, for making core build-ups, splints, adhesive bonding of orthodontic braces, etc.

This is the reason why we have to have an optimal contemporary material to fulfill all the expectations of the dentist and the patient.

It would be ideal to have a material with good esthetic, physical, mechanical and biological properties with optimal handling properties and bioactive potential.

There has been a volcanic eruption of technologies in Endodontics over the past 20 years. The development of NiTi shaping files, the debut of biocompatible materials, the advent of CBCT for improved diagnostics. These minimally invasive technologies promote the maximum preservation of tooth structure, but according to an old aphorism enunciated by Herbert Schilder, for the success of endodontic therapy, “what is removed” is more important than “what is introduced” into the canal system. In this view, laser activated irrigation, and more specifically SWEEPS technology represents a breakthrough method for 3D disinfecting of the root canal system. This unique irrigation method produces fluid cavitation in the root canal system as result of photoacoustic phenomenum generated by erbium YAG laser ultra-short dual pulses energy delivered by the tip kept stationary in the access cavity of the tooth. In this way, the use of EDTA and NaOCl, along the correct protocol, improve the cleaning and decontaminating effect of root canals when compared to conventional methods. The SWEEPS protocol is validated by several in vitro studies, supported by a strong body of published and non-published experiments and data, and confirmed by thousands of clinical trials.

Learning Objectives

1. to understand the main importance of endodontic irrigation in Endodontics
2. to understand the difference among sonic, ultrasonic, multisonic and laser activated irrigation
3. to know the main advantages of SWEEPS technology for root canal irrigation
4. to be aware of the efficacy and effectivenes of LAI/SWEEPS technique in all the steps of R.C.T.