Comparison of clinical outcome of periapical surgery in endodontic and oral surgery units of a teaching dental hospital: a retrospective study

A prospective clinical study of periradicular surgery using mineral trioxide aggregate as a root-end filling

A prospective outcome study of periradicular surgery using microsurgical techniques and root-end filling with mineral trioxide aggregate (MTA) was performed. Nonhealing endodontically treated teeth (n = 321) were included in the study. Surgery was completed under local anesthesia using a standardized clinical protocol. Patients were recalled periodically and examined for signs and symptoms of failure. Thirty-nine teeth were lost from recall. Of the 276 teeth examined, 163 showed complete healing radiographically with no other signs and symptoms; 82 teeth had no symptoms but incomplete or uncertain healing, and 31 teeth showed nonhealing (three had persistent pain despite evidence of complete radiologic healing and eight teeth did not heal for reasons unrelated to the surgical treatment). The overall success rate was 88.8%, including all teeth with no clinical symptoms. In this study, the use of MTA as a root-end filling, following microsurgical techniques, showed a high success rate.

Residual bacteria in root apices removed by a diagonal root-end resection: a histopathological evaluation

AIM

To assess bacteria in the apical portion of the root end after 45 degrees root-end resection in teeth with persistent periapical lesions.

METHODOLOGY

The study included 27 apical root segments from patients with persistent periapical lesions. Histological sections of the coronal part of the amputated root segment were stained with Brown and Brenn to detect the presence of bacteria in the main root canal and/or in irregular root spaces and dentinal tubules. The quality of each root canal filling was evaluated using preoperative radiographs of filling, length of root filling as assessed from the distance between its apical end and the radiographic apex, diameter of apical preparation, and presence of apical perforations or deviations from the root canal. Two endodontists, blinded to the bacteriological results, independently evaluated the radiographs.

RESULTS

Bacteria were present in 23 (85.2%) specimens: five in only the main canal (21.7%), 10 in only the dentinal tubules and irregular spaces (43.5%), and eight in both irregular spaces and dentinal tubules and in the main root canal (34.8%). No correlation was found between the technical quality of the root filling assessed radiographically and bacterial presence in the central canal or irregular areas.

CONCLUSIONS

Infected irregular areas were found in the root tips of teeth with persistent periapical lesions. This was found regardless of the radiographic quality of the root filling. Diagonal, 45 degrees root-end resection may expose such contaminated irregularities to the periapical tissue.

Prospective clinical study evaluating endodontic microsurgery outcomes for cases with lesions of endodontic origin compared with cases with lesions of combined periodontal-endodontic origin

The aim of this study was to evaluate the outcomes of endodontic microsurgery by comparing the healing success of cases having a lesion of endodontic origin compared with cases having a lesion of combined endodontic-periodontal origin. Data were collected from patients in the Department of Conservative Dentistry, Dental College, Yonsei University, Seoul, Korea between March 2001 and June 2005. A total number of 263 teeth from 227 patients requiring periradicular surgery were included in this study. Patients were recalled every 6 months for 2 years and every year thereafter to assess clinical and radiographic signs of healing. A recall rate of 73% (192 of 263 patients) was obtained. The successful outcome for isolated endodontic lesions was 95.2%. In endodontic-periodontal combined lesions, successful outcome was 77.5%, suggesting that lesion type (ABC vs DEF) had a strong effect on tissue and bone healing.

Ultrasonic root-end preparation in apical surgery: a prospective randomized study

OBJECTIVE

The purpose of this study was to evaluate the potential benefit of an ultrasonic device in apical surgery on the outcome of treatment.

STUDY DESIGN

A randomized prospective design was used in a standardized treatment protocol. Patients were allocated to treatment with an ultrasonic device (P-Max Newtron) or treatment with a bur in an otherwise similar protocol. One year after treatment the results were evaluated by 2 oral and maxillofacial surgeons who were blinded for the therapy.

RESULTS

Out of a total group of 399 patients who were included in the study, adequate follow-up could be obtained in 290 patients. The overall success rate in the ultrasonic group was 80.5% and in the group treated with a bur 70.9% (P = .056). In molars, the difference in success rate was significant (P = .02).

CONCLUSION

The use of an ultrasonic device in apical surgery improved the outcome of treatment. In molars this effect was significant.

Modern Endodontic Surgery Concepts and Practice: A Review

Endodontic surgery has now evolved into endodontic microsurgery. By using state-of-the-art equipment, instruments and materials that match biological concepts with clinical practice, we believe that microsurgical approaches produce predictable outcomes in the healing of lesions of endodontic origin. In this review we attempted to provide the most current concepts, techniques, instruments and materials with the aim of demonstrating how far we have come. Our ultimate goal is to assertively teach the future generation of graduate students and also train our colleagues to incorporate these techniques and concepts into everyday practice.

Retrospective Evaluation of Surgical Endodontic Treatment: Traditional versus Modern Technique

The aim of this retrospective study was to compare the outcome of surgical endodontic treatment preformed using the traditional versus modern techniques. There were 110 patients who were treated by surgical endodontic treatment between 2000 and 2002 and evaluated from their dental charts. The surgical endodontic treatment was preformed using a traditional or modern technique. The traditional technique included root-end resection with a 45 degrees bevel angle, and retrograde preparation using a carbide round bur. The modern technique included root-end resection with minimal or no bevel, and retrograde preparation using ultrasonic retro-tips with the aid of a dental operating microscope. The retrograde filling material for both techniques was intermediate restorative material. There were 71 patients with 88 treated teeth that were compatible with the inclusion criteria. Complete healing rate for the teeth treated with the modern technique (91.1%) was significantly higher than that for teeth treated using the traditional technique (44.2%) (p < 0.0001). In the traditional technique a significant (p = 0.032) negative influence of the tooth type was found. Modern surgical endodontic treatment using operative microscope and ultrasonic tips significantly improves the outcome of the therapy compared to the traditional technique.

The management of periapical lesions in endodontically treated teeth

When root canal therapy is done according to accepted clinical principles and under aseptic conditions, the success rate is generally high. However, it has also been reported that 16% to 64.5% of endodontically treated teeth are associated with periapical radiolucent lesions. There are great variations among clinicians when suggesting treatment of these failed endodontic cases. This article will discuss factors influencing treatment decisions on these particular cases, and the pros and cons of nonsurgical retreatment versus surgical retreatment. The advancement of modern endodontic microsurgery will also be discussed.

Endodontics and Implants, a Catalog of Therapeutic Contrasts

Dentists may be faced with the choice to retain a tooth by performing endodontic therapy and restoration or to extract the tooth and replace it with an implant and restoration. The purpose of this study was to catalog areas where implant and endodontic therapies differ so as to assist dentists in making treatment decisions and in identifying areas deserving of future research. Differences in diagnostic procedures and prognostic indicators were listed. With respect to treatment outcomes, study designs, success criteria, treatment results, systematic reviews, complications, clinician expertise, and the use of patient-based measures were discussed. The need for clinically applicable consensus statements and treatment protocols was noted. It was concluded that at this time, choices between implant and endodontic therapies cannot be solely based on outcomes measurement evidence; that different modes of outcome measure frustrate direct comparison; that endodontic and implant therapies profoundly differ in many ways; that although rigorous and clearly defined outcome measures have been proposed for use in endodontic and implant outcomes studies, they are very rarely used; that long-term, large, clearly defined studies, with simple and clear outcome measures, for example survival in combination with defined treatment protocols, are needed to measure the clinical performance of endodontic and implant therapies; and it was recognized that broad outcomes data may not be sufficiently specific to directly impact clinical decision making.

Periapical resurgery versus periapical surgery: a 5-year longitudinal comparison

AIM

To monitor and compare the outcome of periradicular surgery in teeth that had previously undergone surgical treatment versus teeth that were undergoing a surgical procedure for the first time.

METHODOLOGY

A total of 164 patients with 231 roots with previously unresolved periapical lesions were followed for up to 5 years following surgery. In all, 162 roots had received unsuccessful conventional root canal treatment (group AS) and 69 had been treated previously using apical surgery (group RS). The surgical procedure was completed using ultrasonic retrotips to prepare the apical root-end cavity, and a zinc-oxide EBA reinforced material was used to fill the apical root-end cavities. Lesions were radiologically examined from 1 to 5 years following the surgical procedure. Radiographs were independently analysed, according to a previously published classification.

RESULTS

In all the roots examined after 5 years, the overall healing rate was 78%; in group AS, 140 (86%) healed with complete bone filling of the surgical cavity, 12 (7%) were considered to have incompletely healed and 10 (6%) were associated with post-treatment disease. In group RS, 41 (59%) healed completely, 12 (17%) were considered to have incompletely healed and 16 (23%) were associated with post-treatment disease. The difference between a second surgical procedure and a first surgical procedure was statistically significant (Mann-Whitney U-test, P=0.001).

CONCLUSION

Surgical retreatment of teeth previously treated with surgery is a valid alternative to extraction. However, association with post-treatment disease was greater than after a primary surgical approach.

Levels of evidence for the outcome of endodontic surgery

The purpose of this investigation was twofold: (1) to search for clinical articles pertaining to success and failure of periapical surgery and (2) to assign levels of evidence to these studies except case reports. Electronic and manual searches were conducted to identify all the literature regarding success and failure of periapical surgery since 1970. Articles were reviewed, and each article was assigned to a level of evidence from 1 (highest level) to 5 (lowest level). This search located 79 clinical studies. Among these studies, there were no level of evidence-1 randomized clinical trial studies. Five of the seven level of evidence-2 randomized clinical trials compared postoperative pain between surgical and nonsurgical retreatment. Only two level of evidence-2 randomized clinical trials compared the outcomes of surgical treatment with that of nonsurgical treatment. The majority of frequently quoted "success and failure" studies were case series (level of evidence 4).

Prevalence of persistent pain after endodontic treatment and factors affecting its occurrence in cases with complete radiographic healing

AIMS

To (i) determine the prevalence of persistent dento-alveolar pain following nonsurgical and/or surgical endodontic treatment conducted in a teaching dental hospital and (ii) identify the risk factors associated with persistent pain after apparently successful root canal treatment.

STUDY DESIGN

A total of 175 patients/teeth were reviewed 12-59 months following treatment. The patients were examined clinically and radiographically and a detailed pain history obtained. Multiple logistic regression analysis was used to investigate the association between potential risk factors and persistent pain after successful endodontic treatment.

RESULTS

The prevalence of persistent pain after successful root canal treatment was 12% (21/175). Treatment success was determined by the absence of clinical and radiographic signs of dental disease. The factors that were significantly (P < 0.05) associated with persistent pain following endodontic treatment were: 'duration of preoperative pain' [odds ratio (OR) = 8.6], 'preoperative pain from the tooth' (OR = 7.8), 'preoperative tenderness to percussion' (OR = 7.8), 'previous chronic pain problems' (OR = 4.5), 'gender' (OR = 4.5) and 'history of painful treatment in the orofacial region' (OR = 3.8). 'Type of treatment received (surgical or nonsurgical treatment)' showed borderline significance at the 10% level.

CONCLUSIONS

The presence and duration of preoperative pain from the tooth site, lasting at least 3 months, a positive history of previous chronic pain experience or painful treatment in the orofacial region, and female gender were important risk factors associated with persistent pain after successful endodontic treatment.

Treatment Outcome in Endodontics—The Toronto Study. Phases I and II: Apical Surgery

This study prospectively assessed the 4 to 8 yr outcome of apical surgery performed by graduate students in phases I and II of the Toronto Study. The study cohort included 155 teeth in 138 patients. Outcome was assessed by a blinded and calibrated examiner. Clinical and radiographic measures were used for a dichotomous outcome: healed (no signs and symptoms, Periapical Index score </= 2 or scar), or diseased (presence of signs and symptoms, or Periapical Index score >/= 3). The recall rate was 85% and the overall healed rate 74%. Healed rate was significantly higher for teeth with small (</= 5 mm) than larger preoperative lesions (chi, p = 0.02). Logistic Regression revealed an increased odds of disease persistence for teeth with larger preoperative lesions (OR = 3.81, CI = 1.2-12.1), and preoperative root-filling of adequate length (OR = 3.7, CI = 1.1-11.1). Preoperative lesion size and root-filling length were significant predictors of outcome of apical surgery.

Survival of surgical endodontic treatment performed in a dental teaching hospital: a cohort study

AIM

To assess the survival function of surgical endodontic treatment performed at least 1 year before in a dental teaching hospital.

METHODOLOGY

A total of 194 teeth surgically treated between 1991 and 2001 were recalled and examined clinically and radiographically using a set of strict criteria. The Kaplan-Meier method and log rank test were used to evaluate the survival time. Confounding factors were examined by Cox regression analysis.

RESULTS

The median survival time of the 154 first-time surgically treated teeth was 92.1 months (95% CI: 40.9-143.4) and that of the 40 resurgery cases was 39.1 months (95% CI: 6.1-72.1) up to the date of recall. There was a significant difference in the length of survival between the two groups. For those first-time surgery cases, the preoperative marginal bone loss and the operator had a significant influence on the survival time (P < 0.05).

CONCLUSIONS

The survival of surgical endodontic treatment declined nonlinearly with time. The preoperative marginal bone loss, operator and resurgery were important factors affecting the survival of this treatment modality.

Molar apicectomy with amalgam root-end filling: results of a prospective study in two district general hospitals

AIM

To determine the five-year success rates, site or sites of failure, prognostic indicators and lower lip morbidity associated with molar apicectomy using amalgam root-end filling.

DESIGN

Multicentre, prospective study.

SETTING

The departments of oral and maxillo-facial surgery in two district general hospitals.

METHOD

One thousand and seven molar apicectomy procedures, combined with amalgam root-end filling were expedited during the period 1974-1995. A five-year review of each operated tooth was carried out or attempted between 1979-2000.

RESULTS

Of the 790 (78%) operated molars successfully reviewed at 5 years or later 451 (57%) exhibited 'complete healing' and 39 (5%) 'uncertain healing'. Three hundred (38%) were classified as 'unsatisfactory healing' (failures), and these included 12 which were assumed to be of periodontal origin. Whilst longitudinal root fracture, perforation and/or infection in the furcation, periodontal disease or a non-restorable crown accounted for treatment failure and often the need to remove teeth subsequently, the study probably pointed to the apical ends of the roots rather than the furcation as being the major sites at which 'unsatisfactory healing' occurred. Mandibular first molars attracted the highest 'complete healing' rate (60%) and mandibular second molars the lowest (46%). 'Good' root canal treatment (RCT) at the outset improved the prognosis of a root-end filling (REF) whilst the absence of RCT compromised it. Cystic change pointed to a better prognosis than apical granulomatous change as did a deep compared with a shallow 'bone cuff'. Disease at the furcation suggested a worse prognosis. Teeth which showed 'complete healing' at 1 year had a 75% probability of maintaining this outcome at 5 years. Sensory disturbance of variable duration occurred in the lower lip following 20-21% of mandibular molar procedures. In the majority of cases (79-80%) this had remitted within 3 months. A permanent deficit occurred in 8 patients (1%) where the apicectomy could definitely be incriminated as causative. Four were associated with first molar apicectomy and four with second molar apicectomy.

CONCLUSIONS

Molar apicectomy with amalgam root-end filling attracts an overall 'complete healing' rate at 5 years of 57%, the results being best with mandibular first molars and worst with mandibular second molars. The prognosis is also better where there is 'good' initial orthograde root filling, an associated radicular cyst as compared with granulomatous change and where the buccal sulcus is deep rather than shallow. It is worse when orthograde root filling is absent and when there is disease in the furcation. 'Complete healing' at 1 year can be expected to be maintained at 5 years in 75% of cases. The commonest site of subsequent periradicular rarefaction seems to be 'apical' whilst failure at the furcation is probably comparatively rare. There is a threefold increase in the occurrence of permanent lower lip sensory impairment following second molar surgery in comparison with first molar surgery, the overall incidence being 1%.

A prospective clinical study of Mineral Trioxide Aggregate and IRM when used as root-end filling materials in endodontic surgery

AIM

To assess the success rate of the root-end filling material, Mineral Trioxide Aggregate (MTA).

METHODOLOGY

Referred adult patients were recruited using strict entry criteria and randomly allocated to receive MTA or IRM. A standardized surgical technique was employed: the root end was resected perpendicularly and a root-end cavity was prepared ultrasonically and filled. A radiograph taken immediately after surgery was compared with those taken at 12 and 24 months. Customised film holders and the paralleling technique were used; radiographs were assessed by two trained observers using agreed criteria. The results from 122 patients (58 in IRM group, 64 in MTA group) after 12 months and 108 patients (47 in IRM group, 61 in MTA group) for the 24-month review period were analysed using the chi2 test.

RESULTS

The highest number of teeth with complete healing at both times was observed when MTA was used. When the numbers of teeth with complete and incomplete (scar) healing, and those with uncertain and unsatisfactory healing were combined, the success rate for MTA was higher (84% after 12 months, 92% after 24 months) compared with IRM (76% after 12 months, 87% after 24 months). However, statistical analysis showed no significant difference in success between materials (P > 0.05) at both 12 and 24 months.

CONCLUSIONS

In this study, the use of MTA as a root-end filling material resulted in a high success rate that was not significantly better than that obtained using IRM.