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

Analysis of the Prognostic Factors That Influence the Outcome of Periapical Surgery, including Biomimetic Membranes for Tissue Regeneration: A Review

The objective of this study was to analyze the prognostic factors that influence the outcome of periapical surgery. A systematic search of the literature was carried out using PubMed and Scopus databases between January 2000 and December 2023 with no language limitations. The PICO question of the present systematic review was: What prognostic factors may influence the outcome of periapical surgery? The most relevant randomized controlled clinical trials (RCTs), prospective clinical trials, retrospective studies, and meta-analyses (n = 44) were selected from 134 articles. The reviewed literature evidenced that bone-lesion healing could significantly be improved by the absence of deep periodontal pockets (>4 mm), localization in anterior teeth, the absence of pain and/or preoperative symptoms, a size of bone lesion < 5 mm, the use of ultrasound, the correct placement of retrograde filling material, and the use of different biomimetic membranes for guided tissue regeneration (GTR). Some preoperative and intraoperative factors could significantly improve the prognosis of periapical surgery. However, these results were not conclusive, and further high-quality research is required.

The outcome of combined use of iRoot BP Plus and iRoot SP for root-end filling in endodontic microsurgery: a randomized controlled trial

OBJECTIVES

Root-end filling is important for the clinical outcome of endodontic microsurgery. Our previous study showed that combined application of iRoot BP Plus Root Repair Material (BP-RRM) and iRoot SP Injectable Root Canal Sealer (SP-RCS) in root-end filling exhibited better apical sealing as compared to the application of BP-RRM alone. The aim of this randomized controlled clinical trial was to evaluate the effect of the combined use of BP-RRM and SP-RCS on the prognosis of teeth with refractory periapical diseases after endodontic microsurgery.

MATERIALS AND METHODS

240 teeth with refractory periapical diseases scheduled for endodontic microsurgery were randomly divided into BP-RRM/SP-RCS group (n = 120) and BP-RRM group (n = 120). The patients were followed up at 3 months, 6 months, and 12 months after endodontic microsurgery. Pre- and post-operative clinical and radiographic examinations were performed to evaluate the treatment outcome. The 1-year success rate of endodontic microsurgery in BP-RRM/SP-RCS and BP-RRM groups was compared by Chi-square test. Factors that might impact the prognosis were further analyzed using Chi-square test or Fisher's exact test.

RESULTS

A total of 221 teeth completed the 12-month follow-up. The 1-year success rates of the BP-RRM/SP-RCS and BP-RRM groups were 94.5% (104/110) and 92.8% (103/111), respectively. The combined use of BP-RRM and SP-RCS achieved a clinical outcome comparable to BP-RRM alone (P = 0.784). Tooth type (P = 0.002), through-and-through/apico-marginal lesion (P = 0.049), periodontal status (P < 0.0001), and Kim's lesion classification (P < 0.0001) were critical factors associated with the 1-year success of endodontic microsurgery.

CONCLUSIONS

The combined use of BP-RRM and SP-RCS is a practicable method for root-end filling in endodontic microsurgery with a satisfactory 1-year clinical outcome.

CLINICAL RELEVANCE

The combined application of BP-RRM and SP-RCS in EMS is an effective root-end filling method with a satisfactory 1-year clinical outcome.

TRIAL REGISTRATION

This study was registered in the Chinese Clinical Trial Registry (ChiCTR2100052174).

A retrospective study on the prognostic factors and success, survival, and failure outcomes of treated endodontic-periodontal lesions

OBJECTIVES

The objective of this retrospective study was to determine possible prognostic factors of endodontic-periodontal lesions and to compare success, survival, and failure outcomes of treated endodontic-periodontal lesions across different treatment modalities, demographic variables, and anatomical tooth variations.

MATERIALS AND METHODS

Data was collected from patient records in the patient management system (Salud, Titanium Solutions) from the Griffith University Dental Clinic between January 2008 and December 2021. The search strategy used the terms "endodontic periodontal lesion," "periodontal endodontic lesion," "endo perio lesion," "perio endo lesion," and "EPL." The 88 cases which met inclusion and exclusion criteria were analyzed.

RESULTS

The overall success rate was 46.6%, with 21.6% of teeth surviving and 31.8% of teeth failing. Bone loss extending to the apical third (OR = 0.3, 95% CI [0.104, 0.866]), and probing depths of 5-7 mm (OR = 0.147, 95% CI [0.034, 0.633]) and 8-10 mm (OR = 0.126, 95% CI [0.029, 0.542]) were associated with a statistically significant lower odds of success (p < .05). A history of no periodontal disease (OR = 7.705, 95% CI [1.603, 37.037]) was associated with a statistically significant higher odds of success (p < .05).

CONCLUSION

Practitioners should be aware of bone loss to the apical third, deep probing depths, and a history of periodontal disease as possible prognostic factors that can affect the success rate when treating endodontic-periodontal lesions. Further research with more stringent control over operator factors should be done to investigate these variables.

Periapical healing following endodontic microsurgery with collagen-based bone-filling material: A randomized controlled clinical trial

AIM

To evaluate two- and three-dimensionally the effect of resorbable collagen-based bone-filling material on periapical healing of endodontic lesions with four-wall defects following endodontic microsurgery (EMS).

METHODOLOGY

This parallel, randomized controlled superiority clinical trial involved 86 lesions with the strictly endodontic origin and four-wall defect morphology. EMS procedures were performed by calibrated postgraduate residents. Before flap closure, osteotomies were randomized to the control or treatment group. In the control group, the flap was repositioned with no material added. In the treatment group, a collagen-based bone-filling augmentation material was placed into the osteotomy. Clinical and radiographic examinations were completed after 12 months. Periapical healing was evaluated by blinded evaluators using periapical (PA) radiographs according to Molven's criteria and cone beam computed tomography (CBCT) scans according to PENN's 3D criteria. Cortical plate healing was scored according to the RAC/B index. The data were analysed using Fisher's exact test, Logistic regression models and Chi-squared test. The significance level was predetermined at p < .05.

RESULTS

Sixty-six cases were evaluated at the 12-month follow-up, with 30 and 36 cases in the control and treatment groups, respectively. Only the asymptomatic cases (control = 26, treatment = 32) were included in the radiographic evaluation. Twenty-three cases (88.5%) in the control and 28 (87.5%) cases in the treatment group demonstrated complete healing on PA radiographs (p = 1.000). On CBCT, 10 (38.4%) and 21 (65.6%) cases had completely healed in the control and treatment groups, respectively (p = .095). The re-establishment of the buccal cortical plate was detected in 12 (46.2%) and 22 (68.8%) cases in the control and treatment groups, respectively (p = .243).

CONCLUSION

Within the limitations of the present study, the use of collagen-based bone-filling material had no statistically significant effect on the periapical healing of endodontic lesions with four-wall defect following EMS at the 12-month follow-up when evaluated by PA radiographs or CBCT scans. However, the observed higher percentage of a re-established cortical plate in the treatment group could suggest a clinical benefit that is of interest after surgical endodontic treatment.

The effect of hard tissue defects on the clinical outcome of endodontic microsurgery: a systematic review and meta-analysis

OBJECTIVES

The purpose of this systematic review was to appraise the existing literature on the effect of hard tissue defects on the clinical outcome of endodontic microsurgery (EMS).

METHODS

MEDLINE (PubMed), Embase, Web of Science, Cochrane Library and grey literature were searched from January 2000 to May 2023. Study selection and data extraction were performed in duplicate. Eligible studies were critically appraised for the risk of bias using the Cochrane Risk of bias tool. The quality of evidence was assessed using GRADE. Review Manager (RevMan Computer program Version 5.4, The Cochrane Collaboration, 2020) was utilized and the Mantel Haenszel fixed or random effects model was applied, depending on the heterogeneity of the studies. Meta-analysis was performed to estimate the Risk ratio (RR) and 95% Confidence Interval (CIs) to correlate the effects of these factors on treatment outcomes.

RESULTS

Nineteen studies were included. The EMS overall pooled success rate was 84.5%. Five characteristics of hard tissue were identified. The size of the lesion (Small ≤ 5 mm: 78.4% vs. Large > 5 mm: 63.3%, RR = 1.12, 95% CI 1.00-1.26, P ≤ .05), significantly affected the outcomes of EMS. Endodontic lesions exhibited slightly better outcomes than endodontic-periodontal lesions (81.4% vs. 68.2%, RR = 1.14 95% CI 0.98-1.33, P > .05). Cases with the height of the buccal bone > 3 mm also exhibited slightly better outcomes (91.5% vs. 71.4%, RR = 1.20, 95% CI 0.88-1.62, P > .05). Additionally, through and through lesions exhibited better outcomes when grafting was completed during the EMS procedure both in 2D (RR = 1.12 95% CI 0.97-1.29, P > .05) and 3D evaluation ((RR = 1.28 95% CI 0.69-2.37 P > .05). The overall quality of evidence was graded as low to high.

CONCLUSION

With a low to high quality of evidence, the size of the lesion is a key prognostic variable that significantly affects the outcome of EMS, as lesions ≤ 5 mm exhibit better outcomes as compared to larger lesions.

CLINICAL SIGNIFICANCE

The presence of hard tissue defects can affect the outcome of endodontic microsurgery (EMS). The presented data can aid the clinicians' decision-making process by examining certain pre-operative prognostic variables, when considering EMS as a treatment option. Clinical cases with more favorable hard tissue characteristics lead to a better prognosis in EMS.

Clinical Outcome and Predictors of Endodontic Microsurgery Using Cone-beam Computed Tomography: A Retrospective Cohort Study

INTRODUCTION

The aim of this retrospective cohort study was to evaluate the clinical outcomes and identify the prognostic factors of endodontic microsurgery based on cone-beam computed tomographic (CBCT) scans.

METHODS

Patients who underwent endodontic microsurgery in teeth with asymptomatic apical periodontitis were included. The clinical outcomes were determined based on clinical and radiographic examinations after surgery 12-48 months. Radiographic healing was assessed on CBCT images by using the modified PENN 3-dimensional criteria and classified into 4 categories: complete, limited, uncertain, and unsatisfactory healing. Multivariate logistic regression was performed to detect outcome risk factors.

RESULTS

Of the 204 teeth in 173 invited patients, 148 teeth of 126 patients were examined at review. On CBCT images, 88 teeth (59.5%) showed complete healing, and 42 (28.4%) teeth showed limited healing. All these 130 teeth were asymptomatic and achieved a clinical success rate of 87.8%. Uncertain healing was observed in 9 teeth, one of which was symptomatic. The remaining 9 teeth were unsatisfactory healing on CBCT scans, including 6 teeth with clinical symptoms and 3 free. Lesion type and root-end filling quality were significant outcome predictors (P < .05). The risk of treatment failure for teeth with combined endodontic-periodontal lesions was 8.6 times higher than that for teeth with isolated endodontic lesions. Adequate root-end filling quality improved the probability of success by 5.3 times.

CONCLUSIONS

Based on CBCT data, an adequate performed endodontic microsurgery could have predictable success in teeth without periodontal involvement.

Management of Apico-marginal Defects With Endodontic Microsurgery and Guided Tissue Regeneration: A Report of Thirteen Cases

The loss of periodontal tissue support and vertical buccal bone loss in apico-marginal defects can often be mistaken for features indicative of vertical root fractures and this study reports thirteen cases with persistent symptomatic apical periodontitis, apico-marginal defects, and large periapical lesions that were managed with endodontic microsurgery in conjunction with bone grafts and barrier placements with a follow-up period of up to 9 years. At the recall sessions, all cases were asymptomatic with radiographical success with only 2 cases exhibiting residual apical radiolucency, but with evident reduction in the lesion size, indicative of healing. This study highlights the potential of utilizing endodontic microsurgery combined with guided tissue regeneration that proved effective in stimulating the regeneration of periodontal tissue in cases of apico-marginal defects that can lead to favourable long-term outcomes.

Conservative endodontic microsurgery to protect critical anatomical structures-selective curettage: a case series

BACKGROUND

Endodontic microsurgery has yielded highly successful outcomes in preserving teeth with persistent or recurrent cases of periapical periodontitis that could not be successfully treated by nonsurgical endodontic approaches. To avoid complications in conditions in which periapical lesions invade anatomical structures such as the nasopalatine nerve tube and mandibular canal, selective curettage has been proposed as an alternative choice of complete curettage in surgery.

CASE PRESENTATION

The 8 cases reported herein had undergone root canal treatment and/or retreatment but still presented with symptoms, such as recurring sinus tracts and persistent dull pain. The radiographic examination indicated a large area of radiolucency that was associated with the tooth and had invaded adjacent critical anatomical structures. The patients opted for selective curettage via endodontic microsurgery, and the lesions were histologically confirmed as periapical cysts or granulomas. The follow-up results for one year or more indicated that the affected teeth were clinically asymptomatic and exhibited complete or incomplete healing radiographically.

CONCLUSION

This case series provides clinical evidence for the feasibility of selective curettage in endodontic microsurgery, which can avoid complications caused by damage to the adjacent critical anatomical structures.

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.

Comparative histological evaluation of two PRF formulations (PRF High and PRF Medium) on quality of life and healing outcome of apicomarginal defects: A randomized clinical trial

The objective of this randomized clinical trial was to investigate the effects of two PRF formulations (PRF High and PRF Medium) on quality of life and healing outcome (2D and 3D) of apicomarginal defects. Patients presenting with endodontic lesions and concomitant periodontal communication were randomly allocated to PRF High and PRF Medium groups. The treatment protocol in each group included a periapical surgical procedure with placement of PRF clot and membrane in the bony defect and on the denuded root surface, respectively. Quality of life was assessed for 1 week after surgery following a modified version of the patient's perception questionnaire. Postoperative pain was assessed using a visual analog scale. Clinical and radiographic evaluations were performed using Rud and Molven 2D criteria and Modified PENN 3D criteria. Buccal bone formation was assessed using sagittal and corresponding axial sections in CBCT. Histological analysis was performed using hematoxylin and eosin (H and E) staining and attaching primary antibodies to tissue sections. In total, 40 patients were enrolled in the trial (N = 20 per group). PRF Medium group patients reported significantly less swelling on the 1st (p = 0.036), 2nd (p = 0.034), and 3rd (p = 0.023) days, and average pain on the 2nd (p = 0.031), 3rd (p = 0.03), and 4th (p = 0.04) days postoperatively. The difference in success rate for periapical healing was non-significant between the PRF Medium group (89.5%) and PRF High group (90%), in both 2D and 3D imaging (p = 0.957). The formation of buccal bone was observed in five cases (26.3%) and four cases (20%) in the PRF Medium and PRF High groups, respectively, with a non-significant difference (p = 0.575). PRF Medium clots had a loose fibrin structure with a significantly higher number of neutrophils (473.79 ± 82.89 per mm²) than PRF High clots, which had a dense structure and fewer neutrophils (253.15 ± 63.86 per mm²) (p = 0.001). Autologous platelet concentrates (APCs) promoted satisfactory periapical healing, with no significant difference between the groups. Within the limitations of the study, it seems that PRF Medium should be preferred over PRF High when the patients' quality of life is the priority.

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.

Personalized Medicine Based on the Pathogenesis and Risk Assessment of Endodontic-Periodontal Lesions

Endodontic-periodontal lesions (EPLs) are chronic inflammatory lesions in the mouth caused by multiple factors. Both periapical and marginal periodontitis are characterized by infection and inflammation around the affected teeth, suggesting that the theory of complex systems might describe the progression of EPL. The diagnosis and treatment of EPLs are complicated by variations of this condition and difficulties distinguishing EPLs from other diseases. Technological advances in diagnostic and treatment methods, including cone beam computed tomography, microscopy, mineral trioxide aggregates, and periodontal regenerative treatment, have improved outcomes, even in untreatable teeth. However, treating EPLs with iatrogenic problems and/or severe periodontitis remains challenging. Assessing the risk of each EPL based on the possible pathogenesis of each EPL is essential for determining individualized treatment and optimizing personalized medicine for individual patients.

Prognostic Factors of Combined Periodontal and Endodontic Lesions: A Retrospective Study

Objective. This study used a retrospective method to explore the relevant factors affecting the prognosis of periodontal-endodontic combined lesions. Methods. According to the changes of subjective feelings and clinical indicators of affected teeth, selected patients were divided into an effective group and an ineffective group. The natural conditions (age, gender, and smoking status) of the patients and various clinical indicators at the initial and follow-up visits were collected, including the periodontal clinical indicators of the whole mouth and the clinical indicators of the affected teeth. The full-mouth periodontal clinical indicators include periodontal probing depth (PD), clinical attachment loss (CAL), sulcus bleeding index (SBI), and simplified oral hygiene index (OHI.S); clinical indicators of affected teeth include PD, CAL, SBI, mobility (TM), clinical crown-to-root ratio (CR), periapical index (PAI), and number of root canals. Results. There were 74 cases of endodontic combined treatment, with a total of 86 teeth. There was no significant difference in age and gender ratio between the effective group and the ineffective group, and the proportion of smoking patients in the ineffective group was significantly higher than that in the effective group $\left(P<0.05\right)$ . At the initial diagnosis, there was no significant difference in the clinical indicators of the whole mouth between the effective group and the ineffective group. After a combined endodontic treatment, the clinical indicators of the two groups were significantly improved $\left(P<0.01\right)$ . There was no significant difference in other periodontal clinical indicators between the two groups. Conclusion. The prognosis of nonsurgical treatment of periodontal and periodontal combined lesions is mainly correlated to the patient’s oral hygiene maintenance, as well as the loss of attachment, the degree of loosening, the clinical crown-to-root ratio, the periapical index, and the number of root canals.

Factors Affecting the Success of Endodontic Microsurgery: A Cone-Beam Computed Tomography Study

The purpose of this retrospective study was to verify preoperative local parameters of periapical lesions evaluated on cone-beam computed tomography (CBCT) scans as a potential prognostic factor in endodontic microsurgery (EMS). Among 89 cases, local factors (dimensions of lesion, bone destruction pattern, presence/absence of cortical bone destruction, height of buccal bone plate, apical extend of root canal filling, presence/absence of communication with anatomical cavities, type of lesion restriction) were measured on preoperative CBCT images before EMS. At least one year after surgery, the outcome of EMS was classified as a success or a failure. Ten cases (11.24%) were classified as a failure and 79 as a success (88.76%). Symptomatic lesions (OR = 0.088 (95% CI 0.011-0.731); p = 0.024), apicomarginal lesions (OR = 0.092 (0.021-0.402); p = 0.001) and an association with molar teeth (OR = 0.153 (0.032-0.732); p = 0.019) were found as negative predictive factors in the univariate analysis, whereas large apicocoronal dimension (OR = 0.664 (0.477-0.926); p = 0.016), apicomarginal lesions (OR = 0.058 (0.006-0.55); p = 0.013), and an association with molar teeth (OR = 0.047 (0.003-0.869); p = 0.04) were identified as negative predictive factors in the multivariate analysis model. Symptomatic lesions, apicomarginal lesions, lesions associated with molar teeth and large apicocoronal dimensions are significantly associated with the failure of EMS.

Present Status and Future Directions - Surgical Endodontics

Endodontic surgery encompasses several procedures for the treatment of teeth with a history of failed root canal treatment, such as root-end surgery, crown- and root resections, surgical perforation repair, and intentional replantation. Endodontic microsurgery is the evolution of the traditional apicoectomy techniques and incorporates high magnification, ultrasonic root-end preparation and root-end filling with biocompatible filling materials. Modern endodontic surgery uses the dental operating microscope, incorporates cone-beam computed tomography (CBCT) for preoperative diagnosis and treatment planning, and has adopted piezoelectric approaches to osteotomy and root manipulation. Crown- and root resection techniques have benefitted from the same technological advances. This review focuses on the current state of root-end surgery by comparing the techniques and materials applied during endodontic microsurgery to the most widely used earlier methods and materials. The most recent additions to the clinical protocol and technical improvements are discussed, and an outlook on future directions is given. While non-surgical retreatment remains the first choice to address most cases with a history of endodontic failure, modern endodontic microsurgery has become a predictable and minimally invasive alternative for the retention of natural teeth.

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.

A retrospective cohort study on outcome and interactions among prognostic factors of endodontic microsurgery

BACKGROUND/PURPOSE

Endodontic microsurgery (EMS) is a reliable treatment for teeth with non-healing apical periodontitis. This study evaluated the outcome of EMS with mineral trioxide aggregate as the retrograde filling material and identified potential prognostic factors associated with the EMS outcome.

METHODS

Consecutive clinical and radiographic records of EMS performed in a teaching hospital from 2013 to 2017 were reviewed. Cases of root fracture, cemental tear, re-surgery, and incomplete records were excluded. After selection, 268 EMS-treated teeth with the follow-up period more than one year were included. Surgical outcome as success or failure was evaluated according to Molven's criteria. For analysis of potential prognostic factors, multivariate logistic regression was performed followed by bivariate chi-square tests. Stratified analysis was performed to understand the interactions between two prognostic factors.

RESULTS

The overall EMS success rate was 89.9% in this study. Tooth type (anteriors vs. molars, odds ratio (OR) = 6.83, P = 0.001, anteriors vs. premolars, OR = 4.27, P = 0.010) and endodontic-periodontal (endo-perio) communicating defects (with vs. without, OR = 4.92, P = 0.005) both had a significant influence on the EMS outcome. The negative impact of endo-perio communicating defects was closely associated with tooth type. Premolars with endo-perio communicating defects had significantly higher rates of failure.

CONCLUSION

The EMS outcome is significantly affected by the tooth type and endo-perio communicating defect. The presence of endo-perio communicating defects has a greater negative influence on the success rate for premolars than for anteriors and molars.

Impact of Periodontal Attachment Loss on the Outcome of Endodontic Microsurgery: A Systematic Review and Meta-Analysis

Background and Objectives: Endodontic microsurgery (EMS) aims to eradicate the sources of infection once the apical root resection removes most of the infected anatomical structures and repairs potential procedural errors in the apical region. An endodontic-periodontal lesion yields a pathological communication between the pulp and the periodontium. The purpose of this systematic review and meta-analysis is to evaluate the impact of periodontal attachment loss on the outcome of teeth submitted to EMS. Materials and Methods: PRISMA guidelines were followed. An electronic search was performed in EBSCOhost, Embase and PubMed databases with the following search key: (“endodontic microsurgery” AND “outcome”). No filters were used concerning the year of publication or language. Only randomized clinical trials, prospective and retrospective clinical studies in humans, with a minimum one-year follow-up, defined clinical and radiographic outcome criteria and estimable success rate for endodontic-periodontal lesion were included. Statistical analysis was performed using OpenMeta[Analyst] software. Results: Of a total of 113 articles, 34 were selected for full-text reading after duplicates deletion and title and abstract analysis. Thirteen and six studies were included in the systematic review and meta-analysis, respectively. A total of 2775 pooled teeth were submitted to EMS, of which 492 teeth and 4 roots had periodontal involvement. According to the qualitative analysis, success rates of the endodontic-periodontal group ranged from 67.6% to 88.2%. Meta-analysis revealed that the absence of periodontal attachment loss was predictive of a higher likelihood of success with an odds ratio of 3.14. Conclusions: Periodontal attachment loss presents a risk factor for EMS outcome. Although endodontic-periodontal lesions were associated with lower success rates considering a 1 to 10 years follow-up period, long-term successful prognosis following EMS has been reported, therefore presenting a fully valid and viable therapeutic option for the management of this type of lesions.

Evaluation of surface roughness after root resection: An optical profilometer study

The aim of this study was to evaluate the roughness of the apical surface after apical resection performed by six different methods with an optical profilometer. Sixty human single root premolar teeth were used in this in vitro study. After root canal preparation, root canals were filled with gutta-percha and AH Plus root canal sealers by lateral condensation technique. The teeth were randomly divided into six groups according to the apical resection method: steel fissure bur, tungsten carbide fissure bur, Lindeman bur, diamond fissure bur, laser, and ultrasonic surgical piezo with a diamond tip. The root ends were resected 3 mm away from the root apex and at a 90° angle. The time required for apicectomy was recorded for each group. After apical resection, the root surfaces were analyzed by an optical profilometer. The Kruskal-Wallis method was used to analyze the differences between groups. The significance level was set at 5%. The roughest surfaces were obtained by laser (25.54 ± 9.01 μm) and Lindeman bur (17.35 ± 6.03 μm), respectively. The longest mean resection times were recorded in piezosurgery and laser surgery (57 ± 14.39 s and 50.9 ± 16.86 s), respectively. Although the diamond-tipped piezo surgical cutting time is long, it has the best results in terms of surface roughness (5.50 ± 1.73 μm). The optical profilometer is a more convenient tool for evaluating the surface after apical surgery, as it provides an opportunity to evaluate objectively with both visual and numerical data.

Successful management of a tooth with endodontic-periodontal lesion: A case report

BACKGROUND

Endodontic-periodontal lesion is a commonly encountered dental condition. However, the prognosis of the condition varies from good to poor. Some cases are associated with a poor prognosis that requires tooth extraction. This report presents a case of an endodontic-periodontal lesion in a tooth that was successfully treated by root canal treatment.

CASE SUMMARY

A 51-year-old female patient with no medical history complained about persistent pain and discomfort in her left mandibular first molar. Clinical examination showed the left mandibular first molar with poor restoration. It was also associated with underlying necrotic pulp and periodontal involvement. Radiographic examination revealed visible bone defects in the apical and periodontal areas. Based on the findings, the patient was diagnosed with a primary endodontic lesion. A root canal treatment for the endodontic lesion was performed. The patient received a coronal all-ceramic endocrown restoration. A follow-up was arranged to check the prognosis. At the 3 mo follow-up, the clinical and radiography evaluations showed complete disappearance of signs and symptoms and an increase in the radiopacity of the root area.

CONCLUSION

Despite the poor prognosis associated with many endodontic lesions, this case report highlights that a good prognosis is still possible for an endodontic lesion with apical and periodontal bone loss. In this case, it was achieved via successful root canal treatment without the need for periodontal or surgical intervention.

The Buffalo study: Outcome and associated predictors in endodontic microsurgery- a cohort study

AIM

To (i) evaluate and compare the outcome of endodontic microsurgery (EMS) using periapical radiographs (PAs) and cone-beam computed tomography (CBCT) scans; (ii) identify prognostic factors affecting the outcome; and (iii) correlate the effect of guided tissue regeneration (GTR) on the pattern of apical bone remodelling.

METHODOLOGY

Eighty-two patients (101 teeth) who received EMS were included and followed-up using clinical and radiographic examinations (PAs and CBCT scans). Two calibrated endodontists evaluated the radiographic healing (favourable or unfavourable) by assessing PAs and CBCT. The success (favourable radiographic outcome with no clinical symptoms) and survival rates (tooth retention without clinical symptoms) were calculated, and the cause of failure (diseased or fractured) was identified. Pre-treatment (age, sex, tooth type, position, sequence of treatment, quality of root canal before surgery, presence/absence of through-and-through lesion, presence/absence apico-marginal defect) and treatment (presence/absence of errors during surgery, type of error (major or minor), retro-preparation depth, presence/absence of an isthmus, retro-filling material used, presence/absence bone graft material and/or resorbable membrane) factors were recorded. Data were analysed statistically to determine the inter-observer, intra-observer and inter-radiographic agreements. Univariate, bivariate and logistic regression analysis were used to determine prognostic factors affecting the outcome and the effect of GTR on the pattern of apical bone remodelling. The significance level was set at 5%.

RESULTS

Sixty-eight patients (83 teeth) presented for outcome evaluation (recall rate: 84%). The survival rate was 93%. The success rate was 88% using PA and 86% using CBCT when vertical root fracture (VRF) cases were included and 94% using PAs, and 91% using CBCT when VRF cases were excluded. The intra- and inter-observer agreements were substantial using CBCT, slight to a fair agreement using PA (P < 0.001), and slight to moderate for inter-radiographic agreement. The occurence of a major procedural error during surgery was the only negative predictor for the outcome of EMS (P = 0.013). GTR did not affect the success rate or the type of healing when assessed using PA but it affected the type of healing on CBCT scans (complete vs incomplete healing) and the pattern of cortical plate remodelling (P < 0.001).

CONCLUSION

The success and survival rate of endodontic microsurgery was very high, and the occurrence of a major procedural error during surgery was the only factor affecting the outcome. GTR did not improve the outcome, but did affect the quality of apical bone remodelling following EMS.

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.

Prognostic Factors of Long-Term Outcomes in Endodontic Microsurgery: A Retrospective Cohort Study over Five Years

The aim of this study was to analyze the long-term outcomes of endodontic microsurgeries in a cohort and identify their association with prognostic factors. A cohort of endodontic microsurgeries followed up periodically with complete clinical and radiographic records for at least 5 years were reviewed retrospectively. Their survival and healing status and profile characteristics were analyzed by Pearson chi-square test and logistic regression (α = 0.05) to identify prognostic factors that influenced outcomes. Of 652 cases in the cohort, 225 (34.5%) were included. The mean follow-up period was 90.4 months (range, 60–168 months). The long-term success rate was 80.5%, and the 5-year survival rate was 83.5%. Logistic regression showed higher success in anteriors compared to molars (OR = 5.405, (95% CI, 1.663–17.571; p = 0.005)) and in teeth with crown restorations (OR = 10.232, (95% CI, 3.374–31.024; p < 0.001)). Conversely, lower success was found in teeth with periodontal disease (OR = 0.170, (95% CI, 0.032–0.900; p = 0.037)) and maxillary sinus involvement (OR = 0.187, (95% CI, 0.035–0.994; p = 0.049)). Endodontic microsurgery has a highly favorable long-term outcome. Tooth position, crown restoration, periodontal disease, and maxillary sinus involvement were identified as main prognostic factors.

Prognostic Factors of Grade 2-3 Endo-Periodontal Lesions Treated Nonsurgically in Patients with Periodontitis: A Retrospective Case-Control Study

Background

Endo-periodontal lesions are bacterial infectious diseases involving both the periodontal and pulp tissues with poor outcomes. It is hard for clinicians to predict their prognosis. The aim of this study is to investigate the factors affecting the prognosis of endo-periodontal lesions.

Methods

A total of 140 teeth diagnosed with grade 2-3 endo-periodontal lesions in patients with periodontitis were recruited in this study. They were divided into high and low responder groups, according to the clinical symptoms and parameters of the teeth involved after nonsurgical treatment of both the endodontic and periodontal components. Clinical parameters and symptoms were compared before and after treatment, and gender, age, smoking, and all clinical parameters were compared between high and low responder groups using univariate analyses. Logistic regression was applied to evaluate the independent effects on endo-periodontal lesion prognosis.

Results

Compared with the clinical parameters at baseline, the values of tooth mobility (TM), periapical index (PAI), and discomfort when chewing were decreased after endodontic therapy, and the values of periodontal probing depth (PD), clinical attachment level (CAL), sulcus bleeding index (SBI), TM, simplified oral hygiene index (OHI-S), full-mouth periodontitis severity, PAI, and discomfort when chewing were decreased after periodontal therapy. Univariate analysis revealed that smoking, PD, CAL, TM, PAI, clinical crown-root ratio (CR), full-mouth periodontitis severities, and the number of root canals were significantly different between the high and low responder groups (P < 0.05). The logistic regression analysis showed that smoking, PD, CAL, full-mouth periodontitis severities, and the number of root canals remained significantly associated with grade 2-3 endo-periodontal lesions in patients with periodontitis (P < 0.05). The logistic regression analysis showed that smoking, PD, CAL, full-mouth periodontitis severities, and the number of root canals remained significantly associated with grade 2-3 endo-periodontal lesions in patients with periodontitis (

Conclusions

and Practical Implications. High PD and CAL, multirooted teeth, smoking, and serious full-mouth periodontitis indicated a poor prognosis for teeth with grade 2-3 endo-periodontal lesions.

Volume of Voids in Retrograde Filling: Comparison between Calcium Silicate Cement Alone and Combined with a Calcium Silicate-based Sealer

INTRODUCTION

The aim of this study was to compare the volume of voids between retrograde filling using calcium silicate cement alone and retrograde filling using a combination of calcium silicate cement with a calcium silicate-based sealer.

METHODS

Twenty single-rooted, extracted human teeth were instrumented with nickel-titanium files and obturated with gutta-percha. We resected the roots at a point 3 mm from the apex, prepared the root ends, and filled the root-end cavities with Endocem Zr (Maruchi, Wonju, Korea) or Endoseal MTA (Maruchi) plus Endocem Zr. Then, we scanned the prepared samples using micro-computed tomographic imaging and performed 3-dimensional reconstruction. The percentage volume of the gap between the canal wall and root-end filling was calculated along with the percentage volume of voids in the filling materials. All data were analyzed using the Mann-Whitney U test. Selected specimens were further observed using scanning electron microscopy.

RESULTS

There were no significant differences in the percentage volumes of the gaps and internal voids between the 2 groups. Both calcium silicate and the calcium silicate-based sealer exhibited good adaptation to the cavity wall.

CONCLUSIONS

The findings of our micro-computed tomographic and scanning electron microscopic analyses suggested that the volume of voids in retrograde filling using a combination of calcium silicate cement and calcium silicate-based sealer was comparable with that in retrograde filling using calcium silicate cement only. Calcium silicate-based sealers could be used in retrograde filling for clinical convenience without harmful effects on the quality of filling.

Periodontal regenerative therapy in endo-periodontal lesions: a retrospective study over 5 years

Purpose

The aim of this study was to evaluate clinical and radiographic changes and the survival rate after periodontal surgery using deproteinized bovine bone mineral (DBBM) with 10% collagen or DBBM with a collagen membrane in endo-periodontal lesions.

Methods

A total of 52 cases (41 patients) with at least 5 years of follow-up were included in this study. After scaling and root planing with or without endodontic treatment, periodontal regenerative procedures with DBBM with 10% collagen alone or DBBM with a collagen membrane were performed, yielding the DBBM + 10% collagen and DBBM + collagen membrane groups, respectively. Changes in clinical parameters including the plaque index, bleeding on probing, probing pocket depth, gingival recession, relative clinical attachment level, mobility, and radiographic bone gains were evaluated immediately before periodontal surgical procedures and at a 12-month follow-up.

Results

At the 12-month follow-up after regenerative procedures, improvements in clinical parameters and radiographic bone gains were observed in both treatment groups. The DBBM + 10% collagen group showed greater probing pocket depth reduction (4.52±1.06 mm) than the DBBM + collagen membrane group (4.04±0.82 mm). However, there were no significant differences between the groups. Additionally, the radiographic bone gain in the DBBM + 10% collagen group (5.15±1.54 mm) was comparable to that of the DBBM + collagen membrane group (5.35±1.84 mm). The 5-year survival rate of the teeth with endo-periodontal lesions after periodontal regenerative procedures was 92.31%.

Conclusions

This study showed that regenerative procedures using DBBM with 10% collagen alone improved the clinical attachment level and radiographic bone level in endo-periodontal lesions. Successful maintenance of the results after regenerative procedures in endo-periodontal lesions can be obtained by repeated oral hygiene education within strict supportive periodontal treatment.

The use of Enamel Matrix Derivative (Emd) for Treatment of Combined Apicomarginal Lesions in Apical Surgery: A Retrospective Analysis

Objective

The outcome of apical surgery using modern techniques is favourable. However, the presence of a combined apicomarginal defect may negatively affect the postsurgical healing. The objective of this retrospective analysis was to assess the healing of teeth with apicomarginal defects treated with apical surgery and enamel matrix derivative (EMD).

Methods

This retrospective study evaluated the application of EMD in apical surgery of 17 teeth with apicomarginal defects. Cases were followed for at least 1 year, and healing was classified based on established clinical and radiographic criteria.

Results

The patient sample included nine females and eight males with a mean age of 50±18.2 years. Maxillary incisors (six lateral and four central) were the most frequently treated teeth. The majority of apicomarginal defects was located on the facial aspect of the root (70.6%) and belonged to defect class I (76.5%). Follow-up periods ranged from 1 to 5 years. Healing was successful in 14 teeth (82.4%).

Conclusion

The application of EMD resulted in a similar outcome as in previously published clinical studies related to regenerative techniques for the treatment of apicomarginal defects in conjunction with apical surgery.

Successful Management of Teeth with Different Types of Endodontic-Periodontal Lesions

Endodontic-periodontal diseases often present great challenges to the clinician in their diagnosis, management, and prognosis. Understanding the disease process through cause-and-effect relationships between the pulp and supporting periodontal tissues with the aid of rational classifications leads to successful treatment outcomes. In this report, we present several treatment modalities in patients with different endodontic-periodontal lesions. A modification to the new endodontic-periodontic classification, Al-Fouzan's classification, was also added. The first case was classified as retrograde periodontal disease (i.e., primary endodontic lesion with drainage through the periodontal ligament). The second case was diagnosed as an iatrogenic periodontal lesion caused by root perforation. The third case was diagnosed as an iatrogenic periodontal lesion caused by tooth trauma due to orthodontic treatment. The first two cases were managed with a nonsurgical approach, whereas the third case was managed with nonsurgical and surgical approaches. All patients showed complete healing of soft and hard tissue lesions. A thorough understanding of the disease history and the patient's signs and symptoms, complete examination with full investigation, and the use of a systematic step-by-step approach in the management of such challenging endodontic-periodontal lesions with regular recall visits were very useful and successful.

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.

Comparison of the effect of endodontic-periodontal combined lesion on the outcome of endodontic microsurgery with that of isolated endodontic lesion: survival analysis using propensity score analysis

OBJECTIVES

The purpose of this retrospective clinical study was to evaluate the effect of lesion types related to endodontic microsurgery on the clinical outcome.

MATERIALS AND METHODS

Patients who underwent endodontic microsurgery between March 2001 and March 2014 with a postoperative follow-up period of at least 1 year were included in the study. Survival analyses were conducted to compare the clinical outcomes between isolated endodontic lesion group (endo group) and endodontic-periodontal combined lesion group (endo-perio group) and to evaluate other clinical variables. To reduce the effect of selection bias in this study, the estimated propensity scores were used to match the cases of the endo group with those of the endo-perio group.

RESULTS

Among the 414 eligible cases, the 83 cases in the endo-perio group were matched to 166 out of the 331 cases in the endo group based on propensity score matching (PSM). The cumulated success rates of the endo and endo-perio groups were 87.3 and 72.3%, respectively. The median success period of the endo-perio group was 12 years (95% CI: 5.507, 18.498). Lesion type was found to be significant according to both Log-rank test (P = 0.002) and Cox proportional hazard regression analysis (P = 0.001). Among the other clinical variables, sex (female or male), age, and tooth type (anterior, premolar, or molar) were determined to be significant in Cox regression analysis (P < 0.05).

CONCLUSION

Endodontic-periodontal combined lesions had a negative effect on the clinical outcome based on an analysis that utilized PSM, a useful statistical matching method for observational studies.

CLINICAL RELEVANCE

Lesion type is a significant predictor of the outcome of endodontic microsurgery.

Multidisciplinary management of concomitant pulpal and periodontal lesion: A case report

In this case report, the management of a concomitant endodontic-periodontal lesion case is described. A 31-year-old patient presented with symptomatic apical periodontitis of tooth #36 due to failed endodontic treatment and a generalized aggressive periodontitis. Following full-mouth scaling and root-planing, a root-canal retreatment (tooth #36) was initiated. While the distal and mesio-buccal canals were successfully treated, a transportation perforation of the mesio-lingual canal occurred and was repaired by the MTA. An apical microsurgery of the mesial root combined with surgical periodontal debridement for the lower left quadrant was performed. Three weeks later, resective and regenerative periodontal surgeries of the other 3 quadrants were accomplished. Because of the 6-month post-operative healing, the regenerative periodontal surgery for the lower-left quadrant was performed. The 6-month post-operative recall showed complete healing of the mesial root lesion and reduction of the distal root lesion. The multidisciplinary approach and advanced armamentarium contributed to favourable outcome.

Evaluation of Periapical Healing of Apicomarginal Defect in Mandibular First Molar Treated with Platelet Rich Fibrin: A Case Report

The presence of an apicomarginal defect is one of the reasons for the failure of endodontic treatment. The best treatment option to treat an apicomarginal defect is to perform endodontic surgery using Guided Tissue Regeneration (GTR) membranes. The present case report evaluated the healing of periapical lesion along with apicomarginal defect using Platelet Rich Fibrin (PRF) as membrane in periapical surgery of mandibular first molar. Recall examination was performed at 3 and 18 months post surgery. A satisfactory periapical healing was evident using PRF in apicomarginal defect of mandibular first molar. PRF may be considered as an alternative treatment for GTR membranes in the treatment of apicomarginal defects.

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.

Scanning electron microscopic examination of resected root apices obtained from endodontic microsurgery

This study was designed to examine the morphological features of the resected root apices obtained from endodontic microsurgery using a scanning electron microscope (SEM) as well as their anatomical effect on the clinical outcome of the surgical treatment. One-hundred-six resected root apices from 91 patients/surgeries were obtained by endodontic microsurgery, and fixed immediately for storage. The resected apices were prepared for SEM to examine their morphological features, such as the number and size of the apical foramina. The patients were periodically checked up at least 1 year and the clinical outcome of the microsurgery was judged as a success or failure according to the Molven's criteria. The SEM findings and the clinical outcome of apical surgery were evaluated to see any potential correlation between them. The SEM examination revealed that 60.4% of specimens had more than two portals of exit on the resected root apices and the size of the major foramen was at least 386 micrometer and 334 micrometer from maxillary and mandibular molar, respectively. With a recall rate of 72.9%, 91.9% of the surgical cases were decided to have successful outcomes. Based on this SEM study, a relatively high frequency of multiple portals of exit was existed and the sizes of major foramina were bigger than that were reported in previous reports. The clinical outcomes of endodontic microsurgery were not correlated with the anatomical features of resected apical root apices. SCANNING 38:455-461, 2016. © 2016 Wiley Periodicals, Inc.

Haemostatic agents in apical surgery. A systematic review

Background

Blood presence in apical surgery can prevent the correct vision of the surgical field, change the physical properties of filling materials and reduce their sealing ability.

Objetive

To describe which are the most effective and safest haemostatic agents to control bleeding in patients undergoing apical surgery.

Material and Methods

TWe carried out a systematic review, using Medline and Cochrane Library databases, of human clinical studies published in the last 10 years.

Results

The agents that proved more effective in bleeding control were calcium sulphate (100%) and collagen plus epinephrine (92.9%) followed by ferric sulphate (60%), gauze packing (30%) and collagen (16.7%). When using aluminium chloride (Expasyl®), over 90% of the apical lesions improved, but this agent seemed to increase swelling. Epinephrine with collagen did not significantly raise either blood pressure or heart rate.

Conclusions

Despite the use of several haemostatic materials in apical surgery, there is little evidence on their effectiveness and safety. The most effective haemostatic agents were calcium sulphate and epinephrine plus collagen. Epinephrine plus collagen did not seem to significantly raise blood pressure or heart rate during surgery. Aluminium chloride did not increase postoperative pain but could slightly increase postoperative swelling. Randomized clinical trials are needed to assess the haemostatic effectiveness and adverse effects of haemostatic materials in apical surgery.

Key words:Haemostasis, apical surgery.

Scanning electron microscopy reveals severe external root resorption in the large periapical lesion

The present study was designed to investigate the relationships between clinicopathological findings and the resorptive conditions of root apices of teeth with periodontitis. The samples included 21 root apices with large periapical radiolucent lesions. The preoperative computed tomography (CT) and intraoperative findings were correlated with the presence, extension, and the progression pattern of periapical resorption using a scanning electron microscope. The subjects' age, gender, chief complaint, type of tooth, percussion test results, size of periapical lesion using CT, and intraoperative findings were recorded. All apicoectomies were performed under an operative microscope for endodontic microsurgery. A significant large size was observed in cystic lesions compared with granulomatous lesions. The cementum surface at the periphery of the lesion was covered with globular structures (2-3 μm in diameter). Cementum resorption started as small defect formations at the surface. As the defect formation progressed, a lamellar structure appeared at the resorption area, and the size of globular structures became smaller than that of globules at the surface. Further resorption produced typical lacuna formation, which was particularly observed in fracture cases. The most morphologically severe destructive pattern of dentin resorption was observed in large cystic lesions. This study is the first report to elucidate the relationships between three clinical types of undesirable periapical lesions: (1) undertreatment, (2) periapical fracture, (3) macro-level resorption, and the microstructure of external root resorption including from small defects at the cementum surface to a significant destructive pattern inside the dentin. Microsc. Res. Tech. 79:495-500, 2016. © 2016 Wiley Periodicals, Inc.

The effect of human blood on the setting and surface micro-hardness of calcium silicate cements

OBJECTIVES

The purpose of the present study was to evaluate the effects of human blood on the setting and microhardness of calcium silicate cements.

MATERIALS AND METHODS

Three types of silicate-based cements were used: ProRoot MTA (PMTA), OrthoMTA (OMTA), and RetroMTA (RMTA). Mixed cement was placed into polyethylene molds with lengths of 2 and 4 mm. After storage for 4 days under three different storage conditions, i.e., saline, saline after 5 min of human blood, and human blood, the polyethylene molds were removed. With the specimens set, the surface microhardness was measured using a Vickers microhardness tester, crystalline structure was analyzed with X-ray diffraction (XRD), and the surface characteristics were examined with scanning electron microscopy (SEM).

RESULTS

All specimens of 4 mm in length were set with all materials, and the blood groups exhibited lower microhardnesses than did the saline groups (p < 0.05). Among the 2-mm specimens that were stored in blood, the numbers of specimens that set were significantly different across the materials (p < 0.001). Regarding the microhardnesses of the RMTA and OMTA groups, there were no significant differences between storage conditions. For the PMTA group, only one specimen that was set in the blood group exhibited reduced microhardness. XRD showed changes of crystalline structure in the PMTA and OMTA blood group, whereas RMTA did not. SEM analysis revealed more rounded and homogeneous structures and demonstrated a clear lack of acicular or needle-like crystals in the PMTA and OMTA blood groups, while RMTA did not reveal substantial differences between the saline- and blood-stored groups.

CONCLUSION

Blood contamination detrimentally affected the surface microhardnesses of all materials; furthermore, among the 2-mm specimens, blood contamination interfered with normal setting. Therefore, RMTA might be a more suitable choice when blood contamination is unavoidable due to limited depth. Clinical relevance RetroMTA might be a more suitable choice in situations in which blood contamination is unavoidable.

Prognostic factors on periapical surgery: A systematic review

Background

Analyze the most important prognostic factors when performing periapical surgery and compare the success rates of distinct authors.

Introduction

Periapical surgery is an approach to treat non-healing periapical lesions and it should be viewed as an extension of endodontic treatment and not as a separate entity.

Material and Methods

A search of articles published in Cochrane, PubMed (MEDLINE) and Scopus was conducted with the key words “prognostic factors”, “prognosis”, “periapical surgery”, “endodontic surgery” and “surgical endodontic treatment”. The inclusion criteria were articles including at least 10 patients, published in English, for the last 10 years. The exclusion criteria were nonhuman studies and case reports.

Results

33 articles were selected from 321 initially found. Ten articles from 33 were excluded and finally the systematic review included 23 articles: 1 metaanalysis, 1 systematic review, 2 randomized clinical trials, 6 reviews, 12 prospective studies and 1 retrospective study. They were stratified according to their level of scientific evidence using the SORT criteria.

Conclusions

Factors associated with a better outcome of periapical surgery are patients ≤45 years old, upper anterior or premolar teeth, ≤10 sized lesions, non cystic lesions, absence of preoperative signs and symptoms, lesions without periodontal involvement, teeth with an adequate root-filling length, MTA as root-end filling material, uniradicular teeth, absence of perforating lesions, apical resection < 3 mm, teeth not associated to an oroantral fistula and teeth with only one periapical surgery.

Key words:Prognostic factors, prognosis, periapical surgery, endodontic surgery and surgical endodontic treatment.