Introduction: Root canal treatment is considered an ideal treatment option instead of dental extraction to prevent the development of osteoradionecrosis in head and neck cancer (HNC) patients postradiotherapy (RT). This systematic review aimed to assess the impact of RT on pulp vitality in HNC patients. Materials and Methods: The databases of MEDLINE and EMBASE were searched from 1946 up to February 2019 for pulp vitality of the teeth of HNC patients (>16 years old) post-RT. Two authors independently completed the review's stages. The results were summarized narratively. The Joanna Briggs Institute critical appraisal tools were used to assess quality of included papers. Results: 1153 studies were identified and only 2 studies were included in data synthesis. In the two studies, the case and control groups were almost similar according to the source of a similar cohort. Both studies identified confounding variables clearly, but they did not explain strategies used to deal with confounding variables. Conclusions: Pulp vitality might be affected with high doses of RT during treatment (>35 Gy) and at the end of treatment course (60–70 Gy).

Introduction: This systematic review was planned to summarize and quantitatively assess the effect of various tissue regenerative scaffolds on the success of regenerative endodontic techniques in nonvital immature permanent teeth. Materials and Methods: An organized electronic search was conducted through multiple databases. Only randomized controlled trials in patients with nonvital immature teeth were included. The main outcomes were the healing of periapical radiolucency, apical closure, and an increase in root length. The Cochrane risk of bias assessment tool was used for evaluating the risk of bias in the included studies. The quality of each outcome was assessed through the use of the Grading of Recommendations, Assessment, Development, and Evaluation approach. A random-effects model was used for meta-analysis. Results: Sixteen studies involving 153 patients were included, and the overall risk of bias in these studies was moderate. A comparison between blood clot (BC) and platelet-rich plasma (PRP) showed that BC had the greater healing of periapical radiolucency, with an odds ratio (OR) of 3.99; 95% confidence interval (CI): 1.073–14.79; P = 0.04; I² = 0% (certainty of evidence = moderate), as well as greater root length development, with an OR of 2.94; 95% CI: 1.34–6.48; P = 0.007; I² = 83% (certainty of evidence = moderate). However, no significant difference in apical closure had been found between the BC and PRP groups, with an OR of 1.73; 95% CI: 0.53–5.70; P = 0.36; I² = 46% (certainty of evidence = moderate). Conclusions: Moderate quality evidence showed that BC and platelet-rich fibrin are equally effective in the healing of apical radiolucency, apical closure, and an increase in root length of nonvital immature permanent teeth during tissue regeneration. BC scaffold performs better than PRP. Additional well-designed randomized controlled trials on other scaffolds are recommended.

Introduction: The isthmus is a communication between two or more root canals that contains pulp tissue. Its unpredictable location, variable prevalence, and anatomic complexity often result in challenging debridement. The knowledge of these factors may prove beneficial for successful endodontic treatment. The primary aim of this systematic review was to assess the prevalence and morphology of root canal isthmus (RCI) in human permanent teeth using micro-computed tomography (micro-CT) studies. The secondary aim was to assess the influence of demographic factors such as age, gender, and geographic region on the prevalence and morphology of the isthmus. Materials and Methods: An electronic search was conducted until January 2020. Studies published in the English language using micro-CT for the evaluation of isthmus prevalence and morphology were included. Sixteen articles met the inclusion criteria and were subjected to qualitative synthesis. Results: The prevalence of isthmus in the mesiobuccal root of maxillary first molars ranged from 8.9% to 70.8%, with maximum prevalence in the middle third of the root (49.50%–73%). The mesial root of mandibular molars had a prevalence ranging from 80.6% to 100% on full root analysis and 85%–88.89% in the apical third. Conclusion: The prevalence of RCI was higher in the mesiobuccal roots of maxillary molars and the mesial roots of mandibular molars, extending in the corono-apical direction with a complex and variable morphology. The influence of demographic factors on the prevalence of RCI could not be established clearly.

Introduction: Practices followed by dentists for restoring endodontically treated teeth (ETT) vary with a variety of available techniques and materials for post- and-core restorations. The aim of this study was to identify concepts for restoring ETT among dentists in Jeddah, Saudi Arabia. Materials and Methods: A two-section questionnaire was developed using online web-based application (Google forms) and sent to 400 dentists. The first section collected demographic information and the second section concerned about the treatment concept and materials for restoring ETT. Descriptive statistics were used to analyze the data, followed by Chi-square or Fisher's exact test to compare the responses to different questions among general dentists and specialists/consultants. Results: A total of 138 questionnaires were completed. Most of the participants reported a frequently or always use of extracoronal restoration in anteriors (55.1%), premolars (89.1%) and 88.4% for molars. Participant reported frequent placement of posts in anteriors (56.5%), premolars (84.1%) and 64.5% for molars. Nonmetallic post and cast post and core were the preferred option for anteriors and molars, while responses were equally divided between nonmetallic post and cast post and core for premolars. Composite resin was the preferred core material for all teeth. Conclusions: The use of endodontic posts, composite resin as a core and extracoronal restoration for restoring ETT is common among participants. Some of the concepts expressed by the participants are outdated and does not coincide with the evidence-based practice.

Introduction: The aim of this study is to investigate canal configurations and root curvatures of maxillary and mandibular premolar teeth in a Moroccan subpopulation using cone-beam computed tomography (CBCT) images. Materials and Methods: The root curvature and canal configuration of 919 CBCT images of maxillary (358) and mandibular (561) premolar teeth were investigated using “Planmeca viewer” software. Data were analyzed using descriptive statistics. Results: About 46.8% of the maxillary first premolars with two roots had Type I canal configuration of each roots and 27.5% of single-rooted ones presented Type VII. The two-rooted maxillary second premolars showed Type I (39.35%) canal configuration. As for the single-rooted premolars, 32.8% showed Type III canal configuration. The distobuccal curvature was the most frequent for the single-rooted teeth (30.4%) as well as for the palatal (32.4%) root of the two-rooted ones. More than 70% of each root, had Type I of the two rooted mandibular first premolars while 41.8% of the single-rooted premolars had Type V. Type I canal configuration was the most revealed in single-rooted mandibular second premolars with a percentage of 60.6%. Few teeth with two and three roots were seen. The distolingual curvature showed the highest incidence among single-rooted premolars (37.8%) as well as the buccal roots of the two-rooted ones (51.8%). Conclusion: The Moroccan subpopulation's premolars showed a high prevalence of Vertucci's canal configuration Type I with distobuccal curvature for maxillary teeth and distolingual for mandibular teeth.

Introduction: The aseptic measures regarding infection control during root canal treatment are very important. The aim of this study is to assess the attitudes and practices regarding infection control during root canal treatment among dental practitioners in Saudi Arabia. Materials and Methods: Four hundred questionnaires were sent electronically using Twitter and WhatsApp. The questionnaire composed of 17 questions. It was composed of four descriptive questions, five attitude-related questions, and eight practice-related questions. The target subjects were endodontists, Saudi Board in Restorative Dentistry (SBRD) specialists, Pedodontists, their specialty residents, general dentists, and interns. All data were subjected to statistical tests, and a value of P < 0.05 was considered statistically significant. Results: The total number of participants was 327 (82%). There was an overall positive attitude (4.05/5) regarding the importance of infection control. Rubber dam isolation with saliva ejector was the most frequently reported method among Endodontic residents 51 (100%) and SBRD residents 24 (100%) (P = 0.022). Most of the respondents who reported not disinfecting the operative field were Endodontic residents 18 (35.3%) (P = 0.021). The majority of those who reported practicing glove changing before obturation were SBRD residents 14 (58.3%) (P = 0.001). The majority of those who reported gutta-percha disinfection before obturation were Endodontists 49 (90.7%) (P = 0.000). Conclusion: This study showed that dental practitioners in Saudi Arabia were adherent in following the infection control measures during the treatment by self-reported attitudes and practices.

Introduction: The aim of this study was to compare the shaping ability of single-file nickel–titanium systems in simulated S-shaped canals. Materials and Methods: Sixty simulated S-shaped canals were photographed and 12 levels along their length were determined. They were divided into four groups: A and B where the WaveOne Gold and Reciproc Blue reciprocating systems were used and Groups C and D for the OneCurve and Fanta-AF F-one rotary systems. Blocks were re-photographed and the before- and after-preparation photos were superimposed. Canals' widths were measured at each canal's level before and after preparation to calculate canals' deviations. The preparation times were recorded, and the data were analyzed by one-way ANOVA and Chi-square tests (P = 0.050). Results: The mean deviation in the middle third (0.14 mm) was greater than those in the coronal (0.08 mm) and apical thirds (0.09 mm) (P = 0.000). Furthermore, in this third, the OneCurve system caused the lowest greatest deviation (0.13 mm) but not different from the WaveOne Gold system (0.18 mm). At the apical third, the OneCurve showed the least mean deviation (0.07 mm) (P = 0.001) and the lowest mean of the greatest deviation (0.12 mm) (P = 0.000). Significantly, the highest percentage of the greatest deviations located within the canals' middle third (68.4%). The Fanta-AF-F-one and Reciproc Blue systems had higher percentages of the greatest deviation within the middle third (86.7% and 85.7%, respectively) than the OneCurve (42.9%) and WaveOne Gold systems (57.1%) (P = 0.013). The OneCurve and WaveOne Gold systems needed the least shaping times (57.15 and 63.07 s, respectively). Conclusions: The OneCurve system followed by the WaveOne Gold system had better shaping ability than other systems. The OneCurve and WaveOne Gold systems required shorter shaping times. The “greatest-deviation” can be more appropriate analysis than the mean deviation when the shaping ability is investigated.

Introduction: The purpose of this study was to evaluate the effects of different concentrations of chitosan solution used as a final rinse after root canal treatment on the shear bond strength of composite resin to enamel and coronary dentin. Materials and Methods: Sixty-four enamel/dentin fragments were taken from the cervical-third of bovine teeth. The specimens were randomly divided into four groups according to the irrigation protocol (0.2% chitosan, 0.5% chitosan, 1% chitosan, and 17% ethylenediaminetetraacetic acid [EDTA]-control) and in two subgroups according to the substrate (enamel or dentin). Each specimen was fixed in a metallic clamping device and composite resin (Single Bond/z350) was inserted in two increments and polymerized for 20s. The microshear bond strength was performed, and the adhesive interface was analyzed by three-dimensional laser confocal scanning microscopy. The data were analyzed using a two-way ANOVA and Tukey's test (α = 5%). Results: For the irrigation protocol, bond strength was significantly higher for all chitosan solutions compared to the 17% EDTA-control solution. All chitosan solutions, 0.2%, 0.5% and 1.0%, were statistically similar to each other (P > 0.05). For the substrate, enamel showed greater bond strength and was significantly different from dentin (P < 0.05). For interaction factor, 1% chitosan solution presented bond strength values statistically superior to the 17% EDTA control solution (P < 0.05) in dentin. The adhesive fracture was the most prevalent for all groups. Conclusion: The irrigation protocol on the root canal treatment does not affect the enamel bond strength and 1% chitosan solution improved dentin bond strength. Bond strength was higher for enamel than for coronary dentin.

Introduction: The aim of the study was to evaluate the effect of 17% ethylenediaminetetraacetic acid (EDTA) and 7% maleic acid (MA) on shear bond strength of EpoSeal Plus sealer to root canal dentin. Materials and Methods: Twenty-one decoronated maxillary central incisors were longitudinally split into two halves, and each half of the root was further split into three sections, coronal, middle, and apical thirds, respectively, and embedded in dental stone block and abraded with silicon carbide paper to create smear layer. Random division of samples was done into Group 1 (n = 12): 0.9% of saline (5 mL/min), Group 2 (n = 15): 17% EDTA (5 mL/min), and Group 3 (n = 15): 7% MA (5 mL/min). After drying the specimens using paper points, polyethylene tubes were placed on the center of the root canal dentin, and EpoSeal Plus sealer was placed into the tubes, followed by which testing of shear bond strength using a universal testing machine was done. One-way ANOVA and Tukey's honestly significant difference post hoc test was done with a significance level (P = 0.05). Results: The results demonstrated significantly more shear bond strength in MA than EDTA in the middle and apical thirds (P < 0.05), whereas no significant difference was observed in the coronal third (P = 0.05). Conclusion: The shear bond strength of EpoSeal Plus was found to be the maximum at all thirds of root canal dentin when irrigated with 7% MA.

Introduction: The aim of this study was to compare the effect of pentetic acid (diethylenetriaminepentaacetic acid) with ethylenediaminetetraacetic acid (EDTA), as final chelating agents on the pushout bond strength of AH Plus sealer. Materials and Methods: Single-rooted mandibular premolars (n = 80) were collected. The canals were instrumented and were randomly divided into four groups (n = 20) according to the final irrigation protocol followed, where Group I: distilled water, Group II: 3% NaOCl and distilled water final rinse; Group III: 3% NaOCl and 17% EDTA as final irrigant, and Group IV: 3% NaOCl and 5% pentetic acid as final irrigant. Canals were then dried and filled with AH Plus sealer. Roots were sectioned transversely at 4 mm from apex, with 1 mm thickness, and tested for pushout bond strength. Results were analyzed using analysis of variance and post hoc Tukey's test. Results: Pushout bond strength of AH Plus was found to be best with 5% pentetic acid final rinse (0.841 ± 0.15 MPa), followed by 17% EDTA (0.83 ± 0.27 MPa), 3% NaOCl (0.68 ± 0.16 MPa), and distilled water (0.52 ± 0.04). However, there was no statistical difference between 5% pentetic acid and 17% EDTA when used as a final rinse (P < 0.05). The failure modes in Groups III and IV were mixed, whereas Groups I and II showed adhesive failure. Conclusion: Within the limits of the study, 5% pentetic acid was as effective as 17% EDTA and hence can be considered as a potential chelating agent in endodontic therapy.

Introduction: This study aimed to investigate the awareness and clinical practice of the general dental practitioners (GDPs) regarding endodontic treatment in Albaha region, Saudi Arabia. Materials and Methods: An e-questionnaire was distributed among the GDPs in Albaha Province. The e-questionnaire was composed of 21 questions that assessed the awareness and the clinical practice of the GDPs regarding endodontic treatment. The data were collected and statistically analyzed. Results: Fifty-seven (81.42%) out of 70 GDPs responded to the distributed e-questionnaire. Most of the respondents were practicing endodontics on molars (82.4%). A significant difference was observed in performing retreatment between the practitioners who worked in the private sector than peers who worked in the governmental sector (P = 0.015). Noticeably, almost 60% of the participated dentists were not using rubber dam isolation regularly for endodontic procedures. Furthermore, only about 50% of them used cold test for pulpal diagnosis, while 3.5% used electric pulp tester. Few were using intracanal medicament and follow the patients after completing the treatment. Conclusions: A clear deficiency in some aspects of the awareness and clinical endodontic practice of the GDPs in Albaha region was observed. The international and national guidelines of endodontic practice should be implemented.

Introduction: The complex anatomy of the root canal system, the challenging oral environment as well as some patient factors tend to pose challenges to realizing endodontic treatment goals. The aim of this study was to evaluate the complexity of root canal treatment using the Restorative Index of Treatment Need (RIOTN) system. Materials and Methods: This was a descriptive cross-sectional study of patients who received endodontic treatment between May 2018 and July 2019. The data obtained were medical history, tooth for endodontic treatment, and clinical and radiographic findings. The RIOTN system was applied to grade the complexity of root canal treatment. All data garnered were statistically analyzed using IBM SPSS software. Results: The sample population consisted of 114 patients with 124 root-treated teeth. In all, 12.9% of the teeth were graded as complexity Grade 3, 14.5% as Grade 2, and 72.6% as Grade 1. Modifying factors were present in 13.7% of the teeth, with the most prevalent modifying factor being endodontic re-treatment. There was no statistically significant association between number of roots of the teeth and complexity grade (P = 0.57). Conclusion: It is important to grade the complexity of teeth in order to predict the prognosis of treatment and decide whether it is within one's proficiency.

Introduction: Mechanical instrumentation of the root canal system produces an amorphous smear layer. The aim of the present research was to assess the effect of SmearOFF, 7% maleic acid (MA) and 17% ethylenediaminetetraacetic acid (EDTA) when combined with sodium hypochlorite (NaOCl) in removal of smear layer from curved root canals. Materials and Methods: Forty mandibular molars were selected of which only the mesial roots were prepared biomechanically and categorized into four equal groups on the basis of the irrigation protocol: (1) SmearOFF, (2) 7% MA, (3) 17% EDTA, and (4) 0.9% saline. Teeth were then decoronated; mesial roots were cleaved lengthwise and scanning electron microscopic analysis was performed for evaluation of existence of smear layer. Results: On intergroup comparison, there has been found to be notable dissimilarity among the SmearOFF and MA groups in coronal, middle and apical thirds of the root canal system (P > 0.05). However, in EDTA group, there was no notable difference in coronal and middle third. However, in apical one-third, smear layer was cleared less effectively when compared to SmearOFF and MA (P < 0.001). In contrary, all of saline group specimens were extensively smeared in all the parts of the root canal system. On intergroup comparison, all the test irrigants removed smear layer effectively in coronal and middle third of the root canal. Nonetheless, in apical portion, SmearOFF, and MA effectuated significantly better compared to EDTA. Conclusion: In combination with NaOCl, SmearOFF, and MA had superlative smear layer eradication efficacy in contrast to EDTA in apical third of the curved root canals.

Introduction: Students' perspectives regarding their educational experiences play an essential role in curriculum planning and to evaluate effectiveness of dental courses being taught. The current study was aimed to assess the undergraduate dental students' self-perceived confidence level while performing different stages of endodontic treatment. Materials and Methods: A 30-item e-questionnaire was sent to 96 4^th and 5^th year dental students. The students were requested to grade their self-confidence level regarding various stages of endodontic treatment. Moreover, questions related to endodontics discipline difficulty level and students' preferences of file systems were also asked. Data were statistically analyzed. Results: The response rate was 94.8%. The students reported the highest confidence level for treating maxillary anterior teeth (4.39 ± 0.94) and the lowest confidence score was noted for maxillary molars (2.75 ± 1.00). Regarding different stages of endodontic treatment, students exhibited the highest confidence level for rubber dam placement (4.43 ± 0.70) while the lowest confidence was documented for managing inter-appointment flare-up (3.45 ± 0.92). A significant association was noted between the level of the academic year and stages of endodontic treatment for the items related to root canal obturation (P = 0.004) and restoration of endodontically treated teeth (P = 0.01). Considering various endodontic indications, 82.4% of the students were confident/very confident while treating the patients with irreversible pulpitis. Contrary to this, the students were least confident while managing the teeth with immature apices (16.5%). Conclusion: Undergraduate dental students exhibited higher confidence for performing different stages of basic endodontic treatment. Conversely, they reported lower confidence for carrying out more complex procedures.

Introduction: A reproducible glide path provides guidance to fulfil the mechanical objective of cleaning and shaping root canals with minimal procedural errors. Debris expelled during this procedure contributes to inter-appointment flare-up. The objective of this in vitro study was to estimate and compare the quantity of debris extruded by; hand, rotary and reciprocating glide path preparation instruments. Materials and Methods: Seventy-five human single rooted, matured mandibular incisors with single canal and comparable lengths were randomly allocated into three groups (n = 25): group A – Stainless steel (SS) K-file (No 15), Group B – ProGlider, and Group C –WaveOne Gold Glider. Customized apparatus using Meyers and Montgomery method was utilized to accumulate the debris expelled apically in the Eppendorf tubes weighed priorly in digital analytical balance of 10⁻⁶ g accuracy. All groups were instrumented as per the manufacturer's guidelines. After instrumentation, teeth were detached from the Eppendorf tubes and tubes incubated at 70°C for 5 days to vaporize the irrigating solution. The tubes with dry debris were later weighed in the same weighing balance. The collected information was analyzed by one-way ANOVA and Tukeys honest significant difference post hoc test at significance level (P < 0.05). Results: The ProGlider group expressed statistically significant result with least quantity of extruded debris in the comparison to other groups (P < 0.0001). The SS group and WaveOne Gold Glider group exhibited no significant difference, but the debris expelled was less for WaveOne Gold Glider group than SS group. Conclusion: Glide path preparations with rotary ProGlider resulted in the minimal extrusion of debris in comparison to the reciprocating WaveOne Gold Glider and the manual stainless-steel K-files.

Introduction: Glass fiber posts removal is a major obstacle in nonsurgical endodontic retreatment. The currently used removal techniques cause tooth structure loss in different amount. The aim of this study was to evaluate three glass fiber post removal techniques according to their effect on the amount of removed root dentin. Materials and Methods: Endodontic treatment was accomplished for 45 extracted single-rooted teeth. The teeth were decoronated and roots were cut apically at (11 mm) then fiber post spaces were prepared. Photographs of the apical cross-section for post space were taken using a camera at a magnification of 40. Fiber posts were cemented with dual cure resin cement. Then, the samples were divided into three groups (n = 15) depending on the fiber post removal technique: Group (I) DT post removal Kit, Group (II) ultrasonic tips E4D and Group (III) diamond bur and Peeso reamer. Posts were removed and images of the previous section were taken under the same magnification. AutoCAD program was used to compare the spaces difference between before and after removal images. Data were subjected to statistical analysis. Results: The average percentage of removed dentin was (1.89, 0.48, 0.09) cm² in Groups I, II, and III, respectively. Group I showed the highest amount of removed dentin comparing to other groups, but no significant difference between Group II and Group III was recorded (P = 0.000). Conclusion: DT post removal kit group was the most aggressive technique for removing glass fiber.

Introduction: Cryotherapy is a new form of treatment, in which the body is exposed to cold temperatures. Hence, this study was aimed to evaluate the effect of intracanal cryotherapy on postendodontic pain and interleukin-6 (IL-6) expression in teeth with symptomatic apical periodontitis. Materials and Methods: Forty-eight single-rooted teeth in patients with symptomatic apical periodontitis were randomly divided into four groups based on the irrigation protocol. Group I (control): 5% sodium hypochlorite (NaOCl) at room temperature (RT) was used during instrumentation and final rinse. Group II: 5% cold NaOCl (2°C–5°C) was used during the root canal procedure. Group III: 5% NaOCl at RT during instrumentation, while the final rinse was 20 mL of 5% cold NaOCl (2°C–5°C). Group IV: 5% NaOCl at RT during instrumentation followed by 20 mL of cold saline (2°C–5°C). Postoperative pain score was recorded using a modified visual analog scale at 12, 24, 48, and 72 h and after 1 week. Paper point passing 2 mm beyond the apex was used to collect periapical fluid before, immediately after mechanical instrumentation, and after 1 week to characterize the mRNA expression of IL-6 using real-time polymerase chain reaction (PCR). Data were statistically analyzed. The significance level was set at P ≤ 0.05. Results: The control group showed the significant highest mean pain score (7), whereas experimental Groups II, III, and IV showed significantly lower mean pain scores with no significant differences in between (P > 0.05). Group II showed the lowest levels of IL-6 expression with no statistical significance between the experimental groups (P > 0.05). Conclusion: All irrigation protocols using intracanal cryotherapy resulted in lower postoperative pain levels and IL-6 expression than the control group.

The present case report discusses the endodontic management of maxillary lateral incisor with very thin and double-curved root, also known as bayonet-shaped root. A young healthy male patient presented with acute pain in the left maxillary incisor. Clinical examination and radiographic analysis confirmed the diagnosis of previously treated pulp and symptomatic apical periodontitis. Endodontic treatment was carried out with hand and rotary instruments, and the canal was filled using lateral compaction technique. Six-month radiographic follow-up showed good signs of periapical healing. Technique to prepare and obturate such thin and double-curved root requires preoperative measurement of canal curvature angles with creation of glide path to the apex to maintain the taper of the canal and to avoid mishaps.

Mucosal fenestration is a clinical condition wherein the root apex of an affected tooth is visible in the oral cavity due to loss of overlying alveolar bone and mucosa, while dehiscence results in denudation of the root surface due to loss of overlying alveolar bone including the marginal bone. A 25-year-old male patient reported with primary concern of defect in gums and discoloration in an upper central incisor. Examination revealed an intricate case of combined mucosal fenestration and dehiscence occurring concomitantly with an endodontic lesion in an open apex anterior tooth. Cone-beam computed tomographic scan, in addition to routine diagnostic aids, supplemented the diagnosis and facilitated meticulous treatment planning. Both conventional and surgical endodontic procedures were carried out. This was followed by periodontal plastic surgery and prosthodontic rehabilitation of the discolored tooth. Complete healing of soft tissue defect was seen in 6 months, while complete bony healing was seen at 12 months. The treatment thus aimed at correcting the pathology, handling the psychological concerns, and restoring physiologic function and aesthetics by reconstruction of the lost periodontium around the involved tooth.

An accurate diagnosis of the anatomy of the root canal system is a prerequisite for successful endodontic treatment. Morphological variations or additional roots/root canal should always be expected. These variations should be strongly considered before starting any endodontic treatment using various diagnostic aids for better outcome therapy. Nonsurgical endodontic re-treatment of a painful twin-rooted maxillary lateral incisor tooth of a 40-year-old female was carried out due to improper diagnosis of the extra root. The clinical examination and radiographic analysis confirmed the diagnosis of previously treated/necrotic pulp and symptomatic apical periodontitis. The patient remained asymptomatic at 6-month follow-up both clinically and radiographically. The case report emphasized on the need for clinicians to be extra careful while treating such teeth and use of cone-beam computed tomography for their diagnosis and management.

Pulp canal calcification due to dental trauma is described by hard-tissue deposition within the root canal space causing partial or complete obliteration and difficulty in locating canals. Endodontic treatment becomes difficult with increased risk for iatrogenic damage. Guided endodontics is a recent and an alternative solution in such cases. In this case report, a 28-year-old male patient reported with a chief complaint of pain in maxillary lateral incisors and a history of dental trauma that was diagnosed as pulpal necrosis with symptomatic apical periodontitis. The intraoral radiograph was taken, and apical radiolucency was confirmed with cone-beam computed tomography (CBCT) scan. A guided approach was decided for the location of the pulp canal with the use of microendodontic burs. A CBCT scan and an optical surface scan were performed and aligned using software for virtual template designing. The three-dimensional-printed template was positioned on to the tooth and with the help of microendodontic burs; the canal was located and biomechanically prepared using hand instruments. The root canal was obturated, and the cavity was sealed with a composite resin. This method demonstrated an ultraconservative, highly reliable, and successful treatment without the excessive removal of enamel and dentin.

Endodontic therapy has a high success rate. However, failed endodontic therapy with persistent periapical lesions may indicate the presence of an apical cyst that requires surgical apical intervention. The present case involved a 70-year-old woman who was referred after initiation of nonsurgical root canal treatment (NSRCT) in the upper left lateral incisor (tooth #22); due to recurrent swelling and sinus tract. Periapical radiographs showed an apical radiolucency on tooth #22. In a clinical examination, tooth #22 showed a normal response to cold and the electric pulp tester (EPT), while the upper left canine (tooth #23) showed a negative response to cold and the EPT. NSRCT was performed for tooth #23. Eighteen months later, the patient presented with the same chief complaint of recurrent swelling, and cone-beam computed tomography was performed to examine the extent of the apical lesion and plan for surgical intervention. Apical surgery was performed using a dental operating microscope. At the 18-month follow-up assessment, the patient's radiographs showed good bone healing and symptom resolution. This case report indicates that some cases with large persistent periapical lesions may require surgical intervention.