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Periapical endodontic surgery (apical osteotomy, apicoectomy, apicectomy, root resection), aims at the treatment of apical periodontitis, after exhaustion of the possibilities of orthograde endodontics.Surgery is an essential part of endodontics and helps us retain natural teeth as long as possible. Not all periapical lesions are of true endodontic origin and can be treated nonsurgically.With the development of new instruments and techniques, the indications for performing the procedure have changed. Clinicians should know all peculiarities when faced with patients with a different medical history or anatomical variations. They should be prepared to cope with intra/post operative pain and complications.In this review are presented epidemiology, ways of treatment of periapical lesions, advantages and disadvantages, indications and contraindications of performing this procedure, peculiarities with different patients, as well as methods of conducting it, based on the current literature

Periodontally affected teeth with periapical lesion indicated for periapical surgery have a poor prognosis. Using Er:YAG lasers to perform simultaneous surgery on both defects may increase their survival rate. Preparing a retrograde cavity on affected teeth and obturating it is still a matter of debate among clinicians. The purpose of this case report was to describe the simultaneous use of Erbium-doped Yttrium Aluminium Garnet Er:YAG (2,940 nm) laser in the treatment of periapical granuloma and infraossal defect and the achieved results. The Er:YAG laser was used to perform flap dissection, granulation tissue removal, osteotomy and root-end resection except for initial flap incision and reflection. The cystic cavity was filled with Bio-Oss Collagen® xenograft. Results were followed up for 18 months with the help of radiographic orthopantomographic images. The outcome of this clinical case indicates that the use of Er:YAG laser could be considered a suitable method to perform simultaneous periodontal and endodontic surgery.

Introduction: Laser doppler flowmetry is a non-invasive method of measuring microcirculatory blood flow in tissue. Using laser doppler flowmetry Moor VMS-LDF1-HP and CP1T-HP probe combined with Moor VMS-PC software to evaluate the state of the periapical lesion (cyst) before nonsurgical endodontic treatment with bioceramics (Well Root SP™) and compare it to a healthy vital tooth of the same type with no periapical lesions. Later the bony crypt of the cyst was evaluated with Moor VMSLDF1-HP and VP7BS-HP probe during periapical surgery after the cyst was ablated with Er: YAG laser Lite Touch™ (Sineron, Israel) and retrogradely obturated with TheraCal LC®. Then the cyst received a bioceramic bone graft. To our knowledge, this is the first time laser doppler has been used during periapical surgery to evaluate tissue perfusion. Lesion type was confirmed with a histological examination after surgery. Aim: Evaluate tissue perfusion of a periapical lesion before nonsurgical treatment and during surgical endodontic treatment with Er:YAG laser with the help of laser doppler flowmeter. Results: Laser doppler flowmetry shows that the cystic tooth has a decreased blood flow, decreased concentration, direct current, speed, and lower temperature compared to a healthy tooth of the same type. During periapical surgery, the direct laser blood flow evaluation of the surgical crypt shows different values of the flux, speed, direct current, concentration, and temperature, which could be attributed to the mechanical trauma, adrenaline in the local anaesthetic or laser irradiation of tissues. Conclusions: Laser doppler flowmetry is a valuable method to perform tissue evaluation before, during and after treatment. It allows us to follow up the healing and pathological dynamics of microcirculatory tissue changes as well as evaluate and compare different methods and materials for treatment of apical periodontitis.

Main problem in apicoectomy procedures is the choice of access and flap, which determines the prognosis of the affected tooth. An additional complication is the presence of chronic periodontitis and increased tooth mobility. In such cases it is important to maintain the free marginal tissues and to do minimal trauma.  Aim: To show the possibilities of the Er:YAG laser for treatment of apical lesions in a tooth with chronic periodontitis. Materials and Methods: Patient age 35 with moderate to severe chronic periodontitis, and a persistent cyst at tooth 22 was examined. After performing nonsurgical periodontal treatment apicoectomy was scheduled. A semilunar flap with vertical incisions was elevated 3mm from the gingival margin with a blade. All other procedures were performed with the help of Er:YAG laser in modes (release incision, bone remodeling, granulation tissue ablation, apex cutting). No retrograde filling was done. The cyst cavity was filled with Bio-Oss collagen® (Geistlich®, USA).  Results: In the post treatment period a flap dehiscence occurred due to: loose sutures, necrosis, infection. After a period of one year the X-ray showed complete bone filling of the defect with light lucidity at the sight of the dehiscence, which might be merited to the epithelial tissue proliferation towards the defect which resulted in forming bone with lesser density. After one year the tooth is preserved with mobility grade 1.  Discussion: The apicoectomy technique performed with Er:YAG is reliable and kept the soft tissues intact and also the tooth in spite of the severity of the chronic periodontitis. The technique can be recommended in similar cases.