Microscope versus endoscope in root-end management: a randomized controlled study

Advancements in guided surgical endodontics: A scoping review of case report and case series and research implications

This scoping review examined current case series and reports on guided surgical endodontic applications in order to provide a critical platform for future research. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews guidelines were followed. A search on PubMed and Scopus yielded 611 articles, with 17 case reports and 1 series meeting inclusion criteria. Overall, guided surgery addressed anatomical complexities, with 15 articles employing static protocols and 3 dynamic. Results showed minimal iatrogenic errors and reduced chair time, with no postoperative issues reported. Within the cases described, guided endodontic surgery exhibited satisfactory results in management of anatomical complex cases. Cost-effectiveness, the need for adequate follow-up, procedure's reproducibility and accuracy, and objective measurement of the reduction in operative times and iatrogenic errors are some of the limitations in the current reports that need to be considered for planning of future experimental and cohort studies.

Endodontic apical surgery with novel endoscope: Three-case series

Successful apical surgery relies on effective magnification and illumination. In the field of endodontics, the microscope has emerged as the predominant tool for meeting these requirements. The rigid endoscope is also a valuable instrument in apical surgery. This study introduces three cases demonstrating the application of endoscope technology in endodontic apical surgery. The first case employs a soft endoscope for treating an anterior tooth with apical periodontitis, the second integrates an endoscope with new attachments for a premolar, and the third combines an endoscope, attachments and navigation for the lower first molar surgery. It revealed that endoscopes offer certain advantages that are not achievable with microscope-assisted surgery, these cases had a great outcome. In the future, a broader application of endoscopic technology in various procedures is anticipated.

Non-surgical root canal treatment and retreatment versus apical surgery in treating apical periodontitis: A systematic review

BACKGROUND

In addition to non-surgical root canal treatment or retreatment, apical surgery may be carried out to manage teeth with apical periodontitis. However, it is unclear which treatment option is more effective.

OBJECTIVE

To systematically review the effectiveness of apical surgery compared with non-surgical treatment or retreatment in terms of clinical and patient-related outcomes in teeth with apical periodontitis.

METHODS

A literature search of electronic databases, the grey literature, the reference lists of included articles and previous reviews, and a hand search of leading endodontic journals, was conducted. Randomised and non-randomised control trials, and longitudinal observational studies on patients undergoing surgical (treatment group) and non-surgical root canal treatment or retreatment (control group) of teeth with apical periodontitis were included. The risk of bias was appraised using the Cochrane risk-of-bias tool; ROBINS-I and the Newcastle-Ottawa Scale.

RESULTS

Five studies, consisting of two randomised clinical trials, two non-randomised clinical trials, and a retrospective cohort study, were included. The interobserver agreement was high and kappa correlation coefficient was good. In total 529 teeth were available for follow-up that varied from 6 months to 8.7 years. The overall risk of bias was high for four studies and raised some concerns in one study. Apical surgery showed seemly better results regarding periapical healing and less need for more and further intervention, although tooth survival was higher in the control group. Given the heterogeneity of the studies, meta-analysis was not possible.

DISCUSSION

Previous systematic reviews have conducted an indirect comparison by separately pooling the outcomes of studies analysing either non-surgical, or surgical, treatment. In this systematic review, only studies that compared both treatments were included. Most results of this and previous reviews were similar.

CONCLUSION

No treatment option showed clear superiority. However, to arrive at statistically supported conclusions there is a need for additional high-quality comparative trials.

REGISTRATION

PROSPERO database (Registration number CRD42021260300).

Factors that influence the outcomes of surgical endodontic treatment

Surgical endodontic treatment encompasses a broad spectrum of procedures, amongst which root-end cavity preparation and filling, retrograde root canal treatment and through-and-through endodontic surgery, may be classified under the umbrella term 'Root-end surgery'. This narrative review considers the available data on periapical healing, soft tissue healing, tooth survival and oral health-related quality of life (OHRQoL), following root-end surgery and the factors that affect its outcomes. The pooled periapical healed rate for the studies published up to 2021 was 69% (95% CI: 65%, 73%) but increased to 76% (95% CI: 66%, 86%) when only data from the 2020's studies were analysed. The prognostic factors consistently reported for periapical healing have included: pre-operative periapical lesion with complete loss of buccal plate, quality of root-end preparation, remaining thickness of apical root dentine and restorative status. Soft tissue healing of the reflected flap was found to have a positive association with periapical healing. The survival rates following root-end surgery range from 48% to 93%, with failure of periapical healing associated with root and crown fracture, being the predominant reasons for tooth extraction. The factors influencing impact of root-end surgery on patients' quality of life could not be adequately evaluated due to design flaws in the available studies. In conclusion, if root canal treatment failure due to leakage through cracks, fractures or restoration margin are excluded, the remaining cases may represent localized residual infection and inflammation at the periapex that should be amenable to predictable management with the aid of modern root-end surgery.

The effect of imaging modality on the evaluation of the outcome of endodontic surgery

OBJECTIVES

The aim of this study was to assess the effect of the imaging modality on the evaluation of the outcome of modern surgical endodontic treatments, based on a systematic review of the literature.

METHODS

Strict inclusion criteria were adopted in order to identify studies that assessed the outcome of surgical endodontic treatments. Treatment success rates were pooled. The effect of the imaging modality used for the outcome assessment, and the methodological quality of the studies (based on the risk of bias (ROB)), were evaluated.

RESULTS

Nineteen articles were included. The success rates assessed by periapical (PA) radiography were significantly higher than when cases were evaluated by cone beam computed tomography (CBCT; 90 and 35% respectively). This difference was mainly due to a significant proportion of cases that were assessed by CBCT as uncertain healing (48%) compared to only 4% using PA. The success rates ranged between 86 and 92% in low ROB studies, and between 19-100% in high ROB studies.

CONCLUSIONS

Outcome assessment based on CBCT may lead to significantly lower estimates of rate of success, and higher rates of uncertain healing, thus presenting a dilemma in the decision-making following surgical endodontic treatment. The success rates of studies with lower methodological quality are more variable than for high quality studies.

Outcomes reporting in systematic reviews on surgical endodontics: A scoping review for the development of a core outcome set

BACKGROUND

Evidence-informed decision-making in healthcare relies on the translation of research results to everyday clinical practice. A fundamental requirement is that the validity of any healthcare intervention must be supported by the resultant favourable treatment outcome. Unfortunately, differences in study design and the outcome measures evaluated often make it challenging to synthesise the available research evidence required for secondary research analysis and guideline development. Core outcome sets (COS) are defined as an agreed standardised set of outcomes which should be measured and reported as a minimum in all clinical trials on a specific topic. The benefits of COS include less heterogeneity, a reduction in the risk of reporting bias, ensuring all trials contribute data to facilitate meta-analyses, and given the engagement of key stakeholders, it also increases the chances that clinically-relevant outcomes are identified. The recognition of the need for COS for assessing endodontic treatment outcomes lead to the development of Core Outcome Sets for Endodontic Treatment modalities (COSET) protocol, which is registered (No. 1879) on the Core Outcome Measures in Effectiveness Trials (COMET) website.

OBJECTIVES

The objectives of this scoping review are to: (1) identify the outcomes assessed in studies evaluating surgical endodontic procedures; (2) report on the method of assessment used to measure the outcomes; (3) and assess selective reporting bias in the included studies. The data obtained will be used to inform the development of COS for surgical endodontics.

METHODS

A structured literature search of electronic databases and the grey literature was conducted to identify systematic reviews on periradicular surgery (PS), intentional replantation (IR) and tooth/root resection (RR), published between January 1990 and December 2020. Two independent reviewers were involved in the literature selection, data extraction and the appraisal of the studies identified. The type of intervention, outcomes measured, type of outcomes reported (clinician- or patient-reported), outcome measurement method, and follow-up period, were recorded using a standardised form.

RESULTS

Twenty-six systematic reviews consisting of 19 studies for PS, three studies for IR and four studies for RR were selected for inclusion. Outcome measures identified for PS and IR included pain, swelling, mobility and tenderness, outcomes related to periodontal/soft tissue healing (including sinus tract), periradicular healing, tooth survival, life impact (including Oral-Health-Related-Quality-of-Life), resource use and/or adverse effects. For RR, in addition to tooth survival, endodontic complications, and adverse effects, the outcome measures were primarily periodontal-related, including pocket depth reduction, attachment gain, periodontal disease, and periodontic-endodontic lesions. The majority of outcome measures for PS, IR, and RR were assessed clinically, radiologically and/or via patient history. Specific tools such as rating scales (Visual Analog Scale, Verbal rating Scale, Numerical Rating Scale, and other scales) were used for the assessment of pain, swelling, and tenderness, and validated questionnaires were used for the assessment of oral health-related quality of life. The range of follow-up periods were variable, dependent on the outcome measure and the type of intervention.

CONCLUSIONS

Outcome measures, method of assessment and follow-up periods for PS, IR and RR were identified and categorised to help standardise the reporting of outcomes for future research studies. Additional outcome measures that were not reported, but may be considered in the COSET consensus process include loss of root-end filling material, number of clinic visits, surgery-related dental anxiety and muco-gingival aesthetic-related measures, such as scarring, black triangles, root surface exposure, and tissue discolouration.

Prognostic Factors in Endodontic Surgery Using an Endoscope: A 1 Year Retrospective Cohort Study

This retrospective study clarified the success rate of endoscopic endodontic surgeries and identified predictors accounting for successful surgeries. In this retrospective study, 242 patients (90 males, 152 females) who underwent endoscopic endodontic surgery at a single general hospital and were diagnosed through follow-up one year later were included. Risk factors were categorized into attributes, general health, anatomy, and surgery. Then, the correlation coefficient was calculated for the success or failure of endodontic surgery for each variable, the odds ratio was calculated for the upper variable, and factors related to the surgical prognosis factor were identified. The success rate of endodontic surgery was 95.3%, showing that it was a highly predictable treatment. The top three correlation coefficients were post, age, and perilesional sclerotic signs. Among them, the presence of posts was the highest, compared with the odds ratio, which was 9.592. This retrospective study revealed the success rate and risk factors accounting for endoscopic endodontic surgeries. Among the selected clinical variables, the presence of posts was the most decisive risk factor determining the success of endodontic surgeries.

Robotic and Microrobotic Tools for Dental Therapy

Robotic and microrobotic tools such as dental operating microscopes and dental endoscopes are being used extensively in dental therapy, which have a significant impact on dental therapy and education. Herein, this paper reviews the state of the art of robotic and microrobotic tools for dental therapy. This article starts with a brief introduction of current robotic and microrobotic tools for dental therapy and then displays their applications in various dental problems; strengths and weaknesses are also surveyed. Lastly, the conclusion and outlook are discussed, referring to the emerging dental clinic problems and demands. This review is expected to provide guidelines for the therapeutic application of robotic and microrobotic tools and to promote the development of robots in dentistry.

Removal of Horizontally Impacted Mandibular Third Molars With Large Root Bifurcations Using a Modified Tooth Sectioning Method

PURPOSE

The purpose of this study was to introduce the method and first results of a modified tooth sectioning technique for the extraction of horizontally impacted mandibular third molars (M3Ms) with large root bifurcation.

PATIENTS AND METHODS

A total of 300 horizontally impacted M3Ms with large root bifurcation in medically healthy patients were included in this prospective study. Patients were divided into 2 groups: the modified method group (test group), in which the M3M was sectioned between the distal root and the remainder of the tooth at the point of root bifurcation; and the conventional method group (control group), in which the M3M was sectioned between the crown and the root at the cementoenamel junction. Operation duration, postoperative reactions, complications, and patient satisfaction were analyzed and compared between the 2 groups.

RESULTS

Each group included 150 M3Ms which were all successfully extracted. Operation durations in the test and control group were 10.48 ± 3.78 and 15.09 ± 4.24 minutes, respectively (P < .05). The test group had significantly better results than the control group with regard to postoperative reactions and complications (P < .05). Patients in the test group had higher satisfaction ratings regarding operation duration and the healing process than those in the control group (P < .05).

CONCLUSIONS

The modified method of tooth sectioning between the distal root and the remainder of the tooth can efficiently eliminate resistance from the bone and adjacent mandibular second molar and allow for just 1 sectioning of the M3M in most cases, which could make the operation straightforward and safe.

Periapical Microsurgery with an Endoscope and Microscope of Two Upper Central Incisors Already Subjected to Periapical Surgery 25 Years Ago

INTRODUCTION

The present clinical case describes periapical microsurgery with an endoscope and microscope in a patient already treated 25 years ago due to persistent periapical disease of the two central upper incisors, restored with poorly adapted crowns. Clinical Case. The first periapical surgery had been performed with silver amalgam as a retrograde filler material, causing grayish staining of the buccal mucosa. Periapical surgery was performed raising a submarginal flap with ostectomy and apicoectomy, retrograde cavity preparation with ultrasound tips, and filling with mineral trioxide aggregate (MTA). After soft tissue healing and complete bone regeneration of the lesion, retreatment of the incisors with a fixed prosthesis was carried out, adopting the biologically oriented preparation technique (BOPT).

CONCLUSIONS

The described periapical microsurgery approach with magnification and illumination of the surgical field was found to be effective, avoiding the need to extract the two central upper incisors.

The use of the endoscope in endodontic surgery: A systematic review

Background

A systematic review of clinical studies with at least one year of follow-up was done to assess the success rate of endodontic surgery including endoscopy for magnification and illumination.

Material and Methods

Five electronic databases were searched, including MEDLINE (via PubMed), Embase, Web of Science, Scopus and the Cochrane Library of the Cochrane Collabora-tion (CENTRAL). There were no language restrictions, and the search covered the period up to October 2019. The risk of bias was evaluated with the Cochrane Collaboration tool for randomized clinical trials and the ROBINS-I tool for non-randomized studies of inter-ventions.

Results

From the 278 initially identified titles, finally 2 randomized controlled trials and 3 non-randomized studies met the inclusion criteria. All the included studies analyzed the success rate of endodontic surgery performed with the help of endoscope for magnifica-tion and illumination. The risk of bias was high for allocation sequence concealment and blinding of participants and personnel in the randomized controlled trials. The nonran-domized studies showed limitations in terms of confounding bias and blinding of outcome assessment. Endodontic surgery with the help of an endoscope is associated with high success rates (88.9-94.9%).

Conclusions

The endoscope was associated with high success rates of endodontic sur-gery in the included studies. Future studies on this topic are warranted, due to the meth-odological issues and the scarce number of randomized clinical trials.

Key words:Endodontic surgery, magnification, endoscope, success.

Long-Term Prognosis of Endodontic Microsurgery-A Systematic Review and Meta-Analysis

Background and objectives: The long-term outcome of endodontic microsurgery (EMS) performed on root-filled teeth affected by post-treatment apical periodontitis (AP) has been a matter of debate, re-launched by the introduction of novel root-end filling materials which have been proven to improve the short-term outcome of EMS. The purpose of this systematic review and meta-analysis is to evaluate the clinical and radiographic long-term outcome of endodontic microsurgery in teeth diagnosed with secondary AP through radiographic evaluation. Materials and Methods: This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion and exclusion criteria were defined a priori to select the best longitudinal evidence. Only randomized clinical trials (RCT) and prospective clinical studies (PCS), with a follow-up ≥ 2-year, and exhibiting well-established clinical and radiographic outcome criteria, were selected. Results: A total of 573 articles were obtained, from which 10 fulfill inclusion criteria: 6 PCS and 4 RCT. Meta-analysis showed a pooled proportion of success rate of 91.3%, from an overall amount of 453 treated teeth included in RCT; from overall 839 included teeth in PCS, a pooled success rate of 78.4% was observed, with the follow-up time ranging from 2 to 13-years. Survival rate outcomes varied from 79 to 100% for the same follow-up period. Five prognostic factors with influence on the outcome were disclosed: smoking habits, tooth location and type, absence/presence of dentinal defects, interproximal bone level, and root-end filling material. Conclusions: High success rates and predictable results can be expected when EMS is performed by trained endodontists, allowing good prognosis and preservation of teeth affected by secondary AP.

Surgical Strategy of Endoscopically assisted Periradicular Surgery Using Novel Head-mounted Display System

A novel head-mounted display offers high quality of endoscopic imagery in front of the eyes, irrespective of the head position. We present an application of the head-mounted display system as a personal integrated multi-image monitoring system in endoscopically assisted periradicular surgery. Our head-mounted display system displayed multiple forms of information as integrated, sharp, high-definition endoscope, biological monitor, and X-ray image (such as panoramic and computed tomography images) synchronously using a picture in picture. In addition, this system can cope with both the endoscopic field of view and the direct field of view. While monitoring the patient's general condition with a head-mounted display, the surgery was performed with endoscopic animation. We could also switch to the direct surgical field and endoscopic field of view smoothly without moving the head and without surgical interference. The availability of a head-mounted display system during endoscopically assisted periradicular surgery enabled the provision of a comfortable and appropriate surgical environment for the surgeon.

Outcome of Endodontic Surgery: A Meta-analysis of the Literature-Part 3: Comparison of Endodontic Microsurgical Techniques with 2 Different Root-end Filling Materials

INTRODUCTION

The aim of the present study was to investigate the influence of root-end preparation and filling material on endodontic surgery outcome. A systematic review and meta-analysis was conducted to determine the outcome of resin-based endodontic surgery (RES, the use of high-magnification preparation of a shallow and concave root-end cavity and bonded resin-based root-end filling material) versus endodontic microsurgery (EMS, the use of high-magnification ultrasonic root-end preparation and root-end filling with SuperEBA [Keystone Industries, Gibbstown, NJ], IRM [Dentsply Sirona, York, PA], mineral trioxide aggregate [MTA], or other calcium silicate cements).

METHODS

An exhaustive literature search was conducted to identify prognostic studies on the outcome of root-end surgery. Human studies conducted from 1966 to the end of December 2016 in 5 different languages (ie, English, French, German, Italian, and Spanish) were searched in 4 electronic databases (ie, Medline, Embase, PubMed, and Cochrane Library). Relevant review articles on the subject were scrutinized for cross-references. In addition, 5 dental and medical journals (Journal of Endodontics; International Endodontic Journal; Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics; Journal of Oral and Maxillofacial Surgery; and International Journal of Oral and Maxillofacial Surgery) were hand checked dating back to 1975. All abstracts were screened by 3 independent reviewers (H.B., M.K., and F.S.). Strict inclusion-exclusion criteria were defined to identify relevant articles. Raw data were extracted from the full-text review of these selected articles independently by each of the 3 reviewers. In case of disagreement, an agreement was reached by discussion, and qualifying articles were assigned to group RES. For EMS, the same search strategy was performed for the time frame October 2009 to December 2016, whereas up to October 2009 the data were obtained from a previous systematic review with identical criteria and search strategy. Weighted pooled success rates and a relative risk assessment between RES and EMS were calculated. To make a comparison between groups, a random effects model was used.

RESULTS

Sixty-eight articles were eligible for full-text review. Of these, per strict inclusion exclusion criteria, 14 studies qualified, 3 for RES (n = 862) and 11 for EMS (n = 915). Weighted pooled success rates for RES were 82.20% (95% confidence interval [CI], 0.7965-0.8476) and 94.42% for EMS (95% CI, 0.9295-0.9590). This difference was statistically significant (P < .0005).

CONCLUSIONS

The probability for success for EMS proved to be significantly greater than the probability for success for RES, providing best available evidence on the influence of cavity preparation with ultrasonic tips and/or SuperEBA (Keystone Industries, Gibbstown, NJ), IRM (Dentsply Sirona, York, PA), MTA, or silicate cements as root-end filling material instead of a shallow cavity preparation and placement of a resin-based material. Additional large-scale randomized clinical trials are needed to assess other predictors of outcome.

Endodontic procedures for retreatment of periapical lesions

BACKGROUND

When primary root canal therapy fails, periapical lesions can be retreated with or without surgery. Root canal retreatment is a non-surgical procedure that involves removal of root canal filling materials from the tooth, followed by cleaning, shaping and obturating of the canals. Root-end resection is a surgical procedure that involves exposure of the periapical lesion through an osteotomy, surgical removal of the lesion, removal of part of the root-end tip, disinfection and, commonly, retrograde sealing or filling of the apical portion of the remaining root canal. This review updates one published in 2008.

OBJECTIVES

To assess effects of surgical and non-surgical therapy for retreatment of teeth with apical periodontitis.To assess effects of surgical root-end resection under various conditions, for example, when different materials, devices or techniques are used.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Oral Health Trials Register (to 10 February 2016), the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 1), MEDLINE Ovid (1946 to 10 February 2016) and Embase Ovid (1980 to 10 February 2016). We searched the US National Registry of Clinical Trials (ClinicalTrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform for ongoing trials (to 10 February 2016). We placed no restrictions regarding language and publication date. We handsearched the reference lists of the studies retrieved and key journals in the field of endodontics.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) involving people with periapical pathosis. Studies could compare surgery versus non-surgical treatment or could compare different types of surgery. Outcome measures were healing of the periapical lesion assessed after one-year follow-up or longer; postoperative pain and discomfort; and adverse effects such as tooth loss, mobility, soft tissue recession, abscess, infection, neurological damage or loss of root sealing material evaluated through radiographs.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from included studies and assessed their risk of bias. We contacted study authors to obtain missing information. We combined results of trials assessing comparable outcomes using the fixed-effect model, with risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, and 95% confidence intervals (CIs). We used generic inverse variance for split-mouth studies.

MAIN RESULTS

We included 20 RCTs. Two trials at high risk of bias assessed surgery versus a non-surgical approach: root-end resection with root-end filling versus root canal retreatment. The other 18 trials evaluated different surgical protocols: cone beam computed tomography (CBCT) versus periapical radiography for preoperative assessment (one study at high risk of bias); antibiotic prophylaxis versus placebo (one study at unclear risk); different magnification devices (loupes, surgical microscope, endoscope) (two studies at high risk); types of incision (papilla base incision, sulcular incision) (one study at high risk and one at unclear risk); ultrasonic devices versus handpiece burs (one study at high risk); types of root-end filling material (glass ionomer cement, amalgam, intermediate restorative material (IRM), mineral trioxide aggregate (MTA), gutta-percha (GP), super-ethoxy benzoic acid (EBA)) (five studies at high risk of bias, one at unclear risk and one at low risk); grafting versus no grafting (three studies at high risk and one at unclear risk); and low energy level laser therapy versus placebo (irradiation without laser activation) versus control (no use of the laser device) (one study at high risk).There was no clear evidence of superiority of the surgical or non-surgical approach for healing at one-year follow-up (RR 1.15, 95% CI 0.97 to 1.35; two RCTs, 126 participants) or at four- or 10-year follow-up (one RCT, 82 to 95 participants), although the evidence is very low quality. More participants in the surgically treated group reported pain in the first week after treatment (RR 3.34, 95% CI 2.05 to 5.43; one RCT, 87 participants; low quality evidence).In terms of surgical protocols, there was some inconclusive evidence that ultrasonic devices for root-end preparation may improve healing one year after retreatment, when compared with the traditional bur (RR 1.14, 95% CI 1.00 to 1.30; one RCT, 290 participants; low quality evidence).There was evidence of better healing when root-ends were filled with MTA than when they were treated by smoothing of orthograde GP root filling, after one-year follow-up (RR 1.60, 95% CI 1.14 to 2.24; one RCT, 46 participants; low quality evidence).There was no evidence that using CBCT rather than radiography for preoperative evaluation was advantageous for healing (RR 1.02, 95% CI 0.70 to 1.47; one RCT, 39 participants; very low quality evidence), nor that any magnification device affected healing more than any other (loupes versus endoscope at one year: RR 1.05, 95% CI 0.92 to 1.20; microscope versus endoscope at two years: RR 1.01, 95% CI 0.89 to 1.15; one RCT, 70 participants, low quality evidence).There was no evidence that antibiotic prophylaxis reduced incidence of postoperative infection (RR 0.49, 95% CI 0.09 to 2.64; one RCT, 250 participants; low quality evidence).There was some evidence that using a papilla base incision (PBI) may be beneficial for preservation of the interdental papilla compared with complete papilla mobilisation (one RCT (split-mouth), 12 participants/24 sites; very low quality evidence). There was no evidence of less pain in the PBI group at day 1 post surgery (one RCT, 38 participants; very low quality evidence).There was evidence that adjunctive use of a gel of plasma rich in growth factors reduced postoperative pain compared with no grafting (measured on visual analogue scale: one day postoperative MD -51.60 mm, 95% CI -63.43 to -39.77; one RCT, 36 participants; low quality evidence).There was no evidence that use of low energy level laser therapy (LLLT) prevented postoperative pain (very low quality evidence).

AUTHORS' CONCLUSIONS

Available evidence does not provide clinicians with reliable guidelines for treating periapical lesions. Further research is necessary to understand the effects of surgical versus non-surgical approaches, and to determine which surgical procedures provide the best results for periapical lesion healing and postoperative quality of life. Future studies should use standardised techniques and success criteria, precisely defined outcomes and the participant as the unit of analysis.

Magnification devices for endodontic therapy

BACKGROUND

After the introduction of microsurgical principles in endodontics involving new techniques for root canal treatment, there has been a drive to enhance the visualisation of the surgical field. It is important to know if the technical advantages for the operator brought in by magnification devices such as surgical microscopes, endoscopes and magnifying loupes, are also associated with advantages for the patient in terms of improvement of clinical and radiographic outcomes. This version updates the review published in 2009.

OBJECTIVES

To evaluate and compare the effects of endodontic treatment performed with the aid of magnification devices versus endodontic treatment without magnification devices. We also aimed to compare the different magnification devices used in endodontics with one another.

SEARCH METHODS

The following electronic databases were searched: the Cochrane Oral Health Group Trials Register (to 13 October 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2015, Issue 9), MEDLINE via OVID (1946 to 13 October 2015) and EMBASE via OVID (1980 to 13 October 2015). We searched the US National Institutes of Health Trials Register (http://clinicaltrials.gov) and the WHO Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We considered all randomised controlled trials (RCTs) and quasi-randomised controlled trials comparing endodontic therapy performed with versus without one or more magnification devices, as well as randomised and quasi-randomised trials comparing two or more magnification devices used as an adjunct to endodontic therapy.

DATA COLLECTION AND ANALYSIS

We conducted screening of search results independently and in duplicate. We obtained full papers for potentially relevant trials. The Cochrane Collaboration statistical guidelines were to be followed for data synthesis.

MAIN RESULTS

No trials met the inclusion criteria for this review.

AUTHORS' CONCLUSIONS

No article was identified in the current literature that satisfied the criteria for inclusion. It is unknown if and how the type of magnification device affects the treatment outcome, considering the high number of factors that may have a significant impact on the success of endodontic surgical procedure. This should be investigated by further long-term, well-designed RCTs that conform to the CONSORT statement (www.consort-statement.org/).

Removal of impacted mandibular third molars using an inward fragmentation technique (IFT) - Method and first results

PURPOSE

Conventional surgical extraction of impacted mandibular third molars (M3M) requires a lateral flap reflection in conjunction with lateral bone removal for outward mobilization of the tooth. The aim of this report is to outline a novel inward fragmentation technique (IFT) in conjunction with an occlusal miniflap approach to reduce the amount of bone removal to a minimum.

PATIENTS AND METHODS

Seventeen consecutive patients (7 men and 10 women; mean age 24.4 years, range 18-36 years) required the extraction of 21-impacted M3M with a close relationship to the inferior alveolar nerve (IAN). Occlusal miniflaps were used and only occlusal bone removal was performed to expose the M3M under endoscopic vision. A central space-making cavity was created followed by inward fragmentation and mobilization of the crown and subsequent root removal through the space created.

RESULTS

20 of 21 sites healed uneventfully, one late infection was observed, no permanent neurosensory lesion occurred. The mean preoperative buccal bone height was 15.5 (11-18) mm and the postoperative buccal bone height 14.7 (11-17) mm. On the 2nd day, the mean swelling level was 1.38 (0-2) on a 4 point scale, the pain level was 2.30 (0-5) on a 10 cm VAS, mean pain duration was 2.04 days.

CONCLUSION

An inward fragmentation technique allows preservation of >90% of the buccal bone height adjacent to mandibular third molars and may reduce postoperative morbidity without raising the risk of IAN lesions.

Morphological features of the maxillary incisors roots and relationship with neighbouring anatomical structures: possible implications in endodontic surgery

The purpose of this study was to investigate the relationship between the root apex of the upper incisors and neighbouring anatomical structures as well as the morphology of the root-end foramen after apicoectomy. Fifty-seven patients requiring endodontic surgical treatment for a maxillary anterior root were enrolled. A preoperative diagnostic computed tomography (CT) scan was analysed to determine: the distance between the anterior wall of the nasopalatine duct and the central (CI-ND) incisor root 4mm from the apex; and the distance between the floor of the nasal cavity and the tip of either the central (CI-NF) or the lateral (LI-NF) incisor root. After apicoectomy, root-end foramen endoscopic pictures were taken in order to characterize their morphology. Fifty-nine central and 26 lateral incisors were evaluated. The average CI-ND was 4.71 ± 1.26 (SD) mm. The average CI-NF was 10.62 ± 2.25 mm. The average LI-NF was 13.05 ± 2.43 mm. The foramen shape after apicoectomy was ovoid to circular in about 90% of cases in both central and lateral incisors. A sound knowledge of the anatomical relationships at the surgical site is essential for the clinician to perform a safe endodontic surgical procedure.

Outcome of endodontic surgery: a meta-analysis of the literature--Part 2: Comparison of endodontic microsurgical techniques with and without the use of higher magnification

INTRODUCTION

The aim of this study was to investigate the outcome of root-end surgery. It identifies the effect of the surgical operating microscope or the endoscope on the prognosis of endodontic surgery. The specific outcomes of contemporary root-end surgery techniques with microinstruments but only loupes or no visualization aids (contemporary root-end surgery [CRS]) were compared with endodontic microsurgery using the same instruments and materials but with high-power magnification as provided by the surgical operating microscope or the endoscope (endodontic microsurgery [EMS]). The probabilities of success for a comparison of the 2 techniques were determined by means of a meta-analysis and systematic review of the literature. The influence of the tooth type on the outcome was investigated.

METHODS

A comprehensive literature search for longitudinal studies on the outcome of root-end surgery was conducted. Three electronic databases (ie, Medline, Embase, and PubMed) were searched to identify human studies from 1966 up to October 2009 in 5 different languages (ie, English, French, German, Italian, and Spanish). Review articles and relevant articles were searched for cross-references. In addition, 5 dental and medical journals (ie, Journal of Endodontics, International Endodontic Journal, Oral Surgery Oral Medicine Oral Pathology Oral Radiology and Endodontics, Journal of Oral and Maxillofacial Surgery, and International Journal of Oral and Maxillofacial Surgery) dating back to 1975 were hand searched. Following predefined inclusion and exclusion criteria, all articles were screened by 3 independent reviewers (S.B.S., M.R.K., and F.C.S.). Relevant articles were obtained in full-text form, and raw data were extracted independently by each reviewer. After agreement among the reviewers, articles that qualified were assigned to group CRS. Articles belonging to group EMS had already been obtained for part 1 of this meta-analysis. Weighted pooled success rates and a relative risk assessment between CRS and EMS overall as well as for molars, premolars, and anteriors were calculated. A random-effects model was used for a comparison between the groups.

RESULTS

One hundred one articles were identified and obtained for final analysis. In total, 14 studies qualified according to the inclusion and exclusion criteria, 2 being represented in both groups (7 for CRS [n = 610] and 9 for EMS [n = 699]). Weighted pooled success rates calculated from extracted raw data showed an 88% positive outcome for CRS (95% confidence interval, 0.8455-0.9164) and 94% for EMS (95% confidence interval, 0.8889-0.9816). This difference was statistically significant (P < .0005). Relative risk ratio analysis showed that the probability of success for EMS was 1.07 times the probability of success for CRS. Seven studies provided information on the individual tooth type (4 for CRS [n = 457] and 3 for EMS [n = 222]). The difference in probability of success between the groups was statistically significant for molars (n = 193, P = .011). No significant difference was found for the premolar or anterior group (premolar [n = 169], P = .404; anterior [n = 277], P = .715).

CONCLUSIONS

The probability for success for EMS proved to be significantly greater than the probability for success for CRS, providing best available evidence on the influence of high-power magnification rendered by the dental operating microscope or the endoscope. Large-scale randomized clinical trials for statistically valid conclusions for current endodontic questions are needed to make informed decisions for clinical practice.

Apical surgery: A review of current techniques and outcome

Apical surgery is considered a standard oral surgical procedure. It is often a last resort to surgically maintain a tooth with a periapical lesion that cannot be managed with conventional endodontic (re-)treatment. The main goal of apical surgery is to prevent bacterial leakage from the root-canal system into the periradicular tissues by placing a tight root-end filling following root-end resection. Clinicians are advised to utilize a surgical microscope to perform apical surgery to benefit from magnification and illumination. In addition, the application of microsurgical techniques in apical surgery, i.e., gentle incision and flap elevation, production of a small osteotomy, and the use of sonic- or ultrasonic driven microtips, will result in less trauma to the patient and faster postsurgical healing. A major step in apical surgery is to identify possible leakage areas at the cut root face and subsequently to ensure adequate root-end filling. Only a tight and persistent apical obturation will allow periapical healing with good long-term prognosis. The present paper describes current indications, techniques and outcome of apical surgery.

Endodontic treatment of a geminated maxillary second molar using an endoscope as magnification device

AIM

To describe endodontic treatment for a rare case of gemination.

SUMMARY

A case of complex endodontic treatment in a geminated tooth is presented. With the assistance of microinstruments and magnification devices, a geminated maxillary second molar was successfully treated. In such a case, ultrasonic tips and the use of an endoscope were essential to detect the peculiar anatomy of the tooth involved.

KEY LEARNING POINTS

Knowledge of anomalies concerning fused teeth is essential. Using an endoscope as a magnification device is useful during the inspection of pulp chambers. Ultrasonic tips are safe and useful to detect canal orifices.

Magnification devices for endodontic therapy

BACKGROUND

After the introduction of microsurgical principles in endodontics, involving new techniques for root canal treatment, there has been a continuous search for enhancing the visualisation of the surgical field. It would be interesting to know if the technical advantages for the operator brought in by magnification devices like surgical microscope, endoscope and magnifying loupes, are also associated with advantages for the patient, in terms of improvement of clinical and radiographic outcomes.

OBJECTIVES

The purpose of this systematic review was to evaluate and compare the effects of endodontic treatment performed with the aid of magnification devices versus endodontic treatment without magnification devices. We also aimed at comparing among them the different magnification devices used in endodontics (microscope, endoscope, magnifying loupes).

SEARCH STRATEGY

The Cochrane Oral Health Group Trials Register, CENTRAL, MEDLINE and EMBASE were searched with appropriate search strategies. Handsearching included nine dental journals. The bibliographies of relevant clinical trials and relevant articles were checked for identifying studies outside the handsearched journals. Seven manufacturers of instruments in the field of endodontics and/or endodontic surgery, as well as the authors of the identified randomised controlled trials (RCTs) were contacted in order to identify unpublished or ongoing RCTs. There were no language restrictions. The last electronic search was conducted on 2nd April 2009, and the last handsearching was undertaken on 31st January 2009.

SELECTION CRITERIA

All randomised and quasi-randomised trials comparing endodontic therapy performed with or without using one or more types of magnification device, as well as randomised and quasi-randomised trials comparing two or more magnification devices used as an adjunct to endodontic therapy were considered.

DATA COLLECTION AND ANALYSIS

Screening of studies and data extraction were conducted independently and in duplicate. The Cochrane Collaboration statistical guidelines were to be followed for data synthesis.

MAIN RESULTS

No trial could be included in the present review. All of the prospective trials that were identified, all dealing with endodontic surgery, had to be excluded for various reasons. Only one RCT was identified comparing three magnificators (magnifying loupes, surgical microscope, endoscope) in endodontic surgery. No RCT was found that compared the outcome of endodontic therapy using or without using a given magnification device.

AUTHORS' CONCLUSIONS

No objective conclusion can be drawn from the results of this review as no article was identified in the current literature that satisfied the criteria for inclusion. It is unknown if and how the type of magnification device affects the treatment outcome, considering the high number of factors that may have a significant impact on the success of endodontic surgical procedure. This should be investigated by further long-term RCTs with large sample size. Technical advantages of magnificators have been widely reported in low evidence level studies, but they should be systematically addressed to know if there can be the clinical indication for using a given magnification device for specific clinical situations, such as for molar teeth, or if they can all be used interchangeably. Well-designed RCTs should also be performed to determine the true difference in terms of treatment success rates between using or not using a magnification device in both conventional and surgical endodontic treatment, if any exist.