Prognostic Factors for Clinical Outcomes in Endodontic Microsurgery: A Retrospective Study

Two- and three-dimensional healing assessment after endodontic microsurgery in through-and-through periapical lesions: 5-year follow-up from a randomized controlled trial

AIM

To evaluate clinical and radiographic outcome of endodontic microsurgery in through-and-through periapical lesions at 1-year and 5-year follow-up with adjunct use of platelet-rich plasma (PRP).

METHODOLOGY

Thirty-two patients with large through-and-through periapical lesions were randomized in platelet-rich plasma (PRP) group and control group. Two-dimensional (2D) healing was evaluated with Molven's criteria and three-dimensional (3D) healing with modified PENN 3D criteria. Healing at resection plane (R), apical area (A), buccal cortex (BC), palatal cortex (PC) and overall bone healing (B) was assessed using CBCT scans. The volume of lesion was measured using ITK-Snap software. The analysis included comparison of 1- to 5-year intragroup (Friedman test/McNemar test) and intergroup scoring (Chi-square/ Mann-Whitney test). Logistic regression analysis was performed to determine the effect of various factors on healing at 5 years.

RESULTS

Out of 32 patients/59 teeth evaluated after 1-year of endodontic microsurgery, 24 patients/44 teeth reported at 5 - year follow-up. Healing assessment with modified PENN 3D criteria revealed improvement in overall success rate of 66.7% at 1 year to 83.3% at 5 years, with no deterioration in any healing category. PRP group exhibited significantly better 3D healing than control group; both at 1 year (84.6% vs. 45.5%) and 5 years (100% vs. 63.6%). A significantly higher number of completely healed teeth were observed in PRP group than the control group at 5 years with respect to R, BC and B parameters. A volume reduction of 88% (91.4% PRP, 84% control) was depicted at 1 year and 94% (97.1% PRP, 91.1% control) at 5 years. None of the recorded factors including age, gender, size of lesion, preoperative swelling and sinus, histology of lesion, use of PRP, tooth location, preoperative buccal bone had significant effect on 3D healing at 5 years.

CONCLUSIONS

This 5-year study suggested improvement in 3D radiographic healing of large through-and-through periapical lesions from 1 to 5 years with no deterioration in any healing parameter in both control and PRP groups. The additional use of PRP led to significantly better healing in such lesions. RACB index using CBCT allows better estimation of healing at resected, apical and cortical plane over modified PENN 3D or Molven's criteria.

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.

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.

A literature review of local and systemic considerations for endodontic treatments in older adults

OBJECTIVES

The aim of this literature review was to summarise the clinical important findings on the endodontic treatment outcome in older patients (≥60 years old) with pulpal/periapical disease considering local and systemic factors from a body of knowledge that is heterogeneous in methods or disciplines.

BACKGROUND

Due to the increasing number of older patients in the endodontic practice, and the current trend for tooth preservation, the need for clinicians to have a better understanding of age-related implications that may influence the required endodontic treatment in older adults to retain their natural dentition is indispensable.

METHODS

PubMed/Medline and Embase was searched by a medical librarian using specific terms based on inclusion/exclusion criteria. The reference list was hand-seached for additional relevant publications between 2005-2020. A combination of these terms was performed uing Boolean operators and MeSH terms.

RESULTS

Of the 1577 publications identified manually and electronically, 25 were included to be fully reviewed by the examiners. The data was derived from three systematic reviews, one systematic and meta-analysis, three case series, four prospective and 14 retrospective cohorts. Overall, there was heterogeneity in reporting as well as limitations in most studies.

CONCLUSIONS

The outcome of endodontic treatment (ET) either nonsurgical or surgical or combination of these is not affected by older age. ET can be the treatment of choice in older patients wiht pulpal/periapical disease. There is no evidence that older age per se affects the outcome of any type of endodontic treatment.

Effect of orthodontic treatment on the periapical radiolucency of endodontically treated teeth: a CBCT analysis

BACKGROUND

This study aimed to evaluate periapical radiolucency of endodontically treated teeth before and after orthodontic treatment using cone-beam computed tomography (CBCT).

METHODS

Patients who underwent orthodontic treatment at Wonkwang University Daejeon Dental Hospital between January 2009 and June 2022 were included based on the following criteria: root canal treatment, and availability of CBCT images taken before and after orthodontic treatment with an interval of > 1 year between both scans. Patients with primary teeth or orthodontic tooth extractions were excluded. The size of the periapical radiolucency (SPR) of the endodontically treated tooth was evaluated using CBCT. Pre-orthodontic treatment CBCT images and the latest post-orthodontic treatment CBCT images were analyzed. The selected teeth were further categorized based on the orthodontic duration, CBCT interval, the patient sex and age, the tooth type and position (maxilla or mandible), and quality of root canal obturation. Statistical analyses were performed to evaluate changes in SPR using the paired t-test and multiple regression analysis.

RESULTS

In total, 115 teeth (37 anterior teeth, 22 premolars and 56 molars) from 61 patients (age, 14-54 years) were included, with 39 teeth from male patients and 76 teeth from female patients. The age was ranged between 14 and 54 years old, and mean age was 25.87 years old. The mean CBCT interval and orthodontic treatment period were 43.32 months and 36.84 months, respectively. Seventy-five teeth showed good obturation quality, 80 were not used as anchors during orthodontic treatment, and 71 were maxillary. The SPR size increased after orthodontic treatment for 56 teeth and decreased for 59 cases. The average change in SPR was -0.102 mm and the difference was not significant. Significant decrease of SPR were observed between female patients (p = 0.036) and maxillary teeth (p = 0.040).

CONCLUSION

Orthodontic treatment had no significant impact on the changes in the SPR in endodontically treated teeth in most categories. However, there was a significant difference among females and the maxillary teeth. In both categories, the size of radiolucency decreased significantly.

Clinical Effect Evaluation of Concentrated Growth Factor in Endodontic Microsurgery: A Cross-Sectional Study

INTRODUCTION

Concentrated growth factor (CGF) is the third-generation platelet concentrate product. This study aimed to evaluate whether the use of CGF during endodontic microsurgery had a positive influence on surgical outcomes.

METHODS

Fifty-four patients who underwent endodontic microsurgery from January 2017 to November 2021 were enrolled. They were assigned to the CGF and the control group according to whether CGF was used during the surgery and followed up at 6, 12, and 18 months post-surgery. Preoperative classification of the cases and follow-up radiographic outcomes were based on Kim's classification and Molven's criteria respectively and evaluated by two calibrated endodontists. Student t-test and Chi-square test were used to assess the baseline of two groups. Rank sum test was used to determine whether CGF had an impact on the surgical outcome.

RESULTS

Thirty-one patients (41 periapical lesion sites) were included in the CGF group, and twenty-three patients (26 periapical lesion sites) were included in the control group. The overall success rate of endodontic microsurgery was above 90%. The baseline of the two groups had no difference (P<0.05). In the CGF group, the success rate was always 100% in three follow-ups, while the success rate was 84.2%, 92.8%, and 90% respectively in the control group. The success rate between the CGF group and the control group was statistically significant in all three follow-up points (P<0.05).

CONCLUSIONS

The application of CGF during endodontic microsurgery might have a positive influence on surgical outcomes, thus, its prognosis. However, higher-grade evidence is needed to demonstrate its role.

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.

Outcome and associated predictors for nonsurgical management of large cyst-like periapical lesions: A CBCT-based prospective cohort study

AIM

The aim of this cone-beam computed tomography (CBCT)-based study was to evaluate the outcome of nonsurgical root canal treatment (RCT) performed for the management of large cyst-like periapical lesions (LCPL) and to identify the predictive factors affecting healing.

METHODOLOGY

Fifty-four subjects (77 permanent maxillary anterior teeth) with LCPL (>10 mm) of endodontic origin were included. A single operator performed standardized multi-visit RCT. Patients were clinically and radiographically examined at 6, 12 months, and a CBCT scan was taken at 24 months. Two independent blinded evaluators measured the pre- and postoperative volume of periapical lesions on CBCT scans using ITK snap software (version 3.8.0-beta-20181028-win64). The outcome was assessed as a percentage change in lesion volume and dichotomized as success (resolved/reduced) or failure (unchanged/enlarged). Ten preoperative (gender; age; intraoral draining sinus, soft tissue swelling, tooth discoloration, pulp canal obliteration, open apex, root resorption, cortical bone defect and lesion volume) and four intraoperative (apical extent and density of root filling; number of treatment visits and type of root filling) predictive factors were observed. Bivariate and stepwise multivariable linear regression analysis was performed to identify independent predictors affecting treatment outcomes. The significance level was set at 5%.

RESULTS

A recall rate of 88% was achieved. The success rate of RCT was 82.2% (8.9% resolved, 73.3% reduced). Median lesion volume reduction was 75% (IQR 61%-93%). No pre- or intra-operative factors were related to treatment failure. However, presence of preoperative cortical bone defect (palatal versus no cortical defect, β = -51.5; 95% CI: -86.9 to -16, p = .006) and apical extent of obturation (long versus flush, β = -27.2; 95% CI: -53.8 to -0.6, p = .04) were negatively associated with reduction in lesion volume (%).

CONCLUSION

Large cyst-like periapical lesions may be successfully managed with RCT. Preoperative cortical bone defect and apical extent of obturation may negatively influence osseous healing.

Interdisciplinary management of combined periodontal-endodontic lesions with palatogingival grooves of the maxillary lateral incisors: a case report

A palatogingival groove of the maxillary lateral incisor is an anatomic malformation, which always predisposes the tooth to pulpal and periodontal disease. The diagnosis and treatment planning become complicated, with uncertain prognosis. Herein, we present an effective interdisciplinary management of a case of combined periodontal-endodontic lesions caused by palatogingival grooves. A series of treatment modalities were undertaken to preserve the two teeth, including root canal treatment, periodontal initial therapy, splinting the mobile teeth, occlusal adjustment, apical microsurgery, grinding and sealing grooves, and guided tissue regeneration. An apparent healing of the lesions was visible after 12 months. Therefore, interdisciplinary management of combined periodontal-endodontic lesions with palatogingival grooves of the maxillary lateral incisors is necessary for a favourable long-term outcome.

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.

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.

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.

Confocal laser scanning microscopy evaluation of roots subjected to activation protocol in endodontic microsurgery

This study evaluated the penetration of the irrigant subject to activation after performing retro-preparation in endodontic microsurgery. Forty mandibular premolars were prepared and filled. Subsequently, 1 mm from the root apex was cut using a multi-blade bur and the retro-preparation was performed. In group 1, the retro-cavity was cleaned with 2 mL of saline and then with 2 mL of 5.25% NaOCl gel mixed with 0.1% Rhodamine B. In group 2, the retro-cavity was cleaned with 2 mL of saline, 17% EDTA gel was activated ultrasonically for 30 s and 5.25% NaOCl gel was mixed with 0.1% Rhodamine B and activated for 30 s. After 7 days, the roots were cut at 1mm from the apex and the slices were evaluated with confocal laser scanning microscopy. The samples of group 2 showed statistically better results. The activation protocol proposed resulted in enhanced irrigant penetration when compared to the traditional.

Possible Causes for Failure of Endodontic Surgery - A Retrospective Series of 20 Resurgery Cases

OBJECTIVE

This study aimed to evaluate unsuccessful endodontic surgery cases for possible causes for treatment failure and evaluate if a nonsurgical retreatment (NSRTX) approach could have been a better alternative to resurgery.

METHODS

Analyses of clinical and cone-beam computed tomography (CBCT) images, periapical radiographs, and chart documentation determined study parameters. Preoperative factors were age, sex, tooth type, signs and/or symptoms, presence of periapical radiolucency, previous root canal treatment, timeline since previous endodontic surgery, presence of posts, cores, and restorations. The intra-operative factors were microsurgical classification, previous techniques, and current techniques utilized. Postoperative factors were signs and/or symptoms, time to follow-up, and healing status. The accessibility of the root canal system and the quality of the existing root filling were used to evaluate NSRTX as an alternative to resurgery.

RESULTS

A total of 1073 surgical cases from 2011-2019 were reviewed. In 14 patients, 20 cases matched the inclusion criteria and allowed for data extraction. The mean time since the previous surgery was 2.9+-2.1 years, with a mean follow-up of 9.1+-5.8 months after the resurgery. Possible reasons for failure identified were: insufficient root-end filling (leaking, off-axis preparation, lack of depth, overfill) n=12/20, 60.0%; missed anatomy (main and lateral canals, isthmus) n=9/20, 45.0%; incomplete resection n=6/20, 30.0%. In 18/20 cases (90.0%), resurgery appeared to be indicated for 2/20 cases (10.0%). Therefore, NSRTX may have been a potential alternative.

CONCLUSION

Further evidence for possible causes of failure of endodontic surgery was provided, which were primarily iatrogenic. The evaluation of CBCT and high magnification intra-operative images proved beneficial for identifying critical issues for all investigated cases.

Comparison of the sealing ability of various bioceramic materials for endodontic surgery

Objectives

Endosequence Bioceramic Root Repair Material (BC-RRM) is used in endodontic microsurgery. It is available as a paste and a putty. However, no studies to date have examined the sealing ability of these forms alone or in combination as root-end filling materials. Hence, this study aimed to compare the sealing properties of these 2 forms of BC-RRM.

Materials and Methods

Forty-two extracted upper anterior teeth were divided into 3 experimental groups, a positive and negative control. After the root canal treatment, the root ends were resected, retroprepared and retrofilled with either putty, paste + putty or mineral trioxide aggregate (MTA). The teeth were mounted in tubes so the apical 3 mm was submerged in Brain Heart Infusion (BHI) broth. The coronal portions of the canals were inoculated with Enterococcus faecalis and BHI broth and incubated for 30 days. The broth in the tubes was analyzed for colony forming units to check for leakage of bacteria from the canal. The teeth from the groups were sectioned and analyzed using scanning electron microscopy (SEM). The Kruskal-Wallis test and analysis of variance were used to analyze the data with a significance level p < 0.05.

Results

The BC-RRM and MTA groups showed similar sealing ability. The positive control showed leakage in all samples. The SEM imaging showed the presence of bacteria in all experimental groups at the material-tooth interface.

Conclusions

No significant differences were noted in the experimental groups, providing sufficient evidence that any combination could be effectively used during endodontic microsurgery.

Restorative Treatment Patterns After Root Canal Obturation in Public Hospitals in Riyadh

AIM

This study aims to describe the pattern of coronal restoration use among different dental specialties after root canal obturation in two governmental hospitals in Riyadh.

MATERIALS AND METHODS

Electronic dental records at King Abdul-Aziz Medical City and University Dental Hospital were reviewed. Teeth that underwent initial root canal treatment on a permanent tooth for obturation using gutta-percha between April 2019 and June 2019 were included. The collected data included the type of material used for coronal restoration after RCT, immediate post-space preparation, cotton pellet placement, the clinical title and specialty of the treating physician, and the center where treatment was performed. Excel was used for data collection. IBM SPSS was used for descriptive and interferential analyses.

RESULTS

A total of 763 patients were included in the study, in which the double seal technique was used in 56% of the patients, followed by Cavit, which was used in approximately 17% of the patients. Post space was prepared immediately after root canal treatment in 49 patients, and only 17 teeth received the final post, whereas post space was temporized for the rest of the prepared teeth and received the final post at the following visits. Significant relations were found between the type of material used and the clinical title of the treating physician and between the material of choice and the specialty of the dentist. The double seal was the technique of choice among endodontists and restorative dentists, whereas advanced general dentists frequently used Cavit. The least used materials were IRM, amalgam, and Ketac Silver.

CONCLUSION

The double seal technique was found to be the most commonly used method to achieve a coronal seal, followed by Cavit. Other materials used after RCT, in sequential order based on the frequency of use, were GIC, temporary crowns, resin composite, RMGIC, prefabricated post with composite buildup, IRM, amalgam, and Ketac Silver.

Outcome of Periapical Surgery in Molars: A Retrospective Analysis of 424 Teeth

INTRODUCTION

The objective of this retrospective study was to assess the outcome of periapical surgery in a large number of molars in order to identify possible variables that might affect the outcome.

METHODS

The healing outcome of patients undergoing periapical surgery of molars from October 1999 to October 2019 was retrospectively evaluated. Outcome was dichotomized into "healed" and "nonhealed" using well-established clinical and radiographic healing criteria. The potential influence of patient-, tooth-, and treatment-related parameters on the healing outcome was analyzed.

RESULTS

A total of 424 molars in the same number of patients (45.5% male and 54.5% female) were evaluated. Three hundred seventy-two molars were classified as healed (87.7%). Three significant outcome predictors were identified: 1-year follow-up versus >1-5 years, >5-10 years, and >10 years (95.3% vs 82.2%, 76.3%, and 76.5% healed, respectively; P < .0001); root end filling material with bioceramic root repair material versus mineral trioxide aggregate (96.9% vs. 86.3% healed, respectively; P = .001); and preoperative evaluation based on cone-beam computed tomographic imaging versus 2-dimensional radiography (90.2% vs 81.4% healed, respectively; P = .02). Sex, age, tooth location, type of restoration, attachment level, presence of a post, quality of the root canal filling, technique of root end preparation, administration of antibiotics, and type of surgery had no significant impact on the healing outcome.

CONCLUSIONS

The healed rate for the concave (Retroplast) and cavity (mineral trioxide aggregate, SuperEBA [Staident International, Staines, UK], and bioceramic root repair material) root end preparation technique over all follow-up periods was 84% and 88.5%, respectively. The follow-up period, root end filling material, and preoperative evaluation based on cone-beam computed tomographic imaging had a significant influence on the healing outcome.

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.

A retrospective study of endodontic microsurgery about 302 patients

OBJECTIVES

To investigate the outcome of endodontic microsurgery and analyze the potential prognostic factors, and to evaluate the value of surgical classification by Kim and Kratchman.

METHODS

Collecting clinical examination and radiographical examination of endodontic microsurgery cases (which were followed up at least 1 year), which were classified according to Kim and Kratchman, and we analyzed the outcome of endodontic microsurgery and its potential prognostic factors.

RESULTS

302 patients (400 teeth) who received endodontic microsurgery were included. The one year success rate of endodontic microsurgery was 94.25%. Different classification had significant influences on the outcome of endodontic microsurgery (P<0.05), and the success rate of class B and C were better than those of class D, E, and F. The position of teeth had significant influences on the outcome of endodontic microsurgery (P<0.05). The success rate of maxillary teeth was higher than that of mandibular teeth. The success rate of anterior teeth was higher than that of posterior teeth (P<0.05). The quality of root end filling and first or second surgery had no effect on the outcome (P>0.05).

CONCLUSIONS

Endodontic microsurgery is an effective treatment method for saving affected teeth, and it can get a good result. Tooth position and classification are the potential prognostic factors. The surgical classification of Kim and Kratchman can help to predict the outcome of endodontic microsurgery.

The effect of retrograde material type and surgical techniques on the success rate of surgical endodontic retreatment: systematic review of prospective randomized clinical trials

Background

Endodontic surgical procedures, when performed, require retrograde filling materials that are biocompatible, non-toxic, non-irritant, dimensionally stable, and ideally promote bone formation. Precise evaluation of retrograde filling materials in clinical trials is necessary to give holistic view for properties of material and potential outcome from its use. The purpose of this review is to evaluate the effect of retrograde material type and surgical techniques on the success rate of surgical endodontic retreatment.

Methods

An electronic search was performed in the time frame between 1st of January 2000 to 1st of September 2020 using database.

Sources

Web of Science, PubMed and redundant hand searches through their references. Seven inclusion–exclusion criteria were set for the selection and identification of relevant articles. Risk of bias was conducted for the included studies.

Results

Nine randomized clinical trials (RCTs) fulfilled the inclusion criteria for this systematic review. The outcome of this review revealed that none of the reviewed trials totally-fulfilled CONSORT 2010 criteria.

Conclusions

In light of the outcome of this review, there is no enough evidence to support the superiority of certain retrograde filling material or surgical technique over another in the success rate of surgical endodontics retreatment. The variety of methodologies and strategies, such as patient selection, the method of treatment and study analysis, led to doubtful credibility of the obtained clinical evidence. Further prospective randomized controlled clinical trials evaluating the specific effect of the various used materials are needed.

Prognostic Factors after Endodontic Microsurgery: A Retrospective Study of 111 Cases with 5 to 9 Years of Follow-up

INTRODUCTION

A study was performed of the healing rate of teeth subjected to endodontic microsurgery after a minimum follow-up of 5 years with an analysis of the influence of different pre- and postoperative factors on the outcome.

METHODS

This was a retrospective study of patients subjected to endodontic microsurgery with the use of mineral trioxide aggregate (MTA) for retrograde filling between January 2011 and December 2015. In patients with multiple treated teeth, only 1 random tooth was selected for the statistical analysis. Clinical and radiographic parameters were used to assess healing. Simple binary logistic regression models were used to analyze the influence of patient age and sex, the type of tooth, prior radiographic lesion size, the presence of a post, the type of restoration, and the apical extent of prior filling of the root canal on the endodontic microsurgery success rate. Two calibrated observers evaluated the periapical radiographs on an independent basis.

RESULTS

A total of 111 patients (63.1% women and 36.9% men) were included in the study. Of the 111 teeth analyzed, 90 were classified as healed (mean healing rate = 81.1%). Patient age and sex, the presence of a post, the type of tooth, the type of restoration, and the apical extent of prior filling of the root canal had no significant impact on the outcome. Large lesions (>5 mm) were associated with a lower healing rate than smaller lesions, although the difference was not significant. Anterior teeth had a significantly higher healing rate (93.8% maxillary and 100% mandibular) than molars (70.8% maxillary and 57.1% mandibular) (P < .05). The differences between the anterior teeth and the molars were statistically significant.

CONCLUSIONS

The mean healing rate of teeth subjected to endodontic microsurgery was 81% after 5-9 years of follow-up. The success rate was lower for upper and lower molars than for teeth in the anterior zone, although the sample was small and further studies are needed to establish whether the type of tooth influences the treatment outcome.

A One-Year Radiographic Healing Assessment after Endodontic Microsurgery Using Cone-Beam Computed Tomographic Scans

This study aimed to evaluate one-year radiographic healing after endodontic microsurgery using CBCT with modified PENN 3D criteria and to compare the outcome with results evaluated using Molven’s criteria. A total of 107 teeth from 96 patients were evaluated one year after endodontic microsurgery by using CBCT scans with modified PENN 3D criteria and periapical radiographs with Molven’s criteria. Both preoperative and postoperative lesion volumes were calculated using ITK-SNAP (free software). Radiographic healing assessment using periapical radiographs and CBCT images, and preoperative and postoperative lesion volume measurements were performed independently by two examiners. The assessment using Molven’s criteria resulted in 75 complete healings, 18 incomplete healings, eight uncertain healings, and six unsatisfactory healings. Based on modified PENN 3D criteria, 64 teeth were categorized as complete healing, 29 teeth as limited healing, six teeth as uncertain healing, and eight teeth as unsatisfactory healing. With the one-year follow-up, CBCT scans showed a lower healing tendency than did periapical radiography. The volumes of apical radiolucency after the surgery were reduced by 77.7% on average at one-year follow up.

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.

Topographic Analysis of the Isthmus in Mesiobuccal and Mesial Roots of First Molars in a South Korean Population

The purpose of this study was to evaluate the incidence and microscopic anatomy of the isthmus to provide more precise anatomical information about the mesiobuccal (MB) roots of the maxillary first molars and the mesial (M) roots of the mandibular first molars. Twenty-eight maxillary and 31 mandibular first molars were embedded, sectioned, stained, and observed at 30× magnification to evaluate the incidence and microscopic anatomy of the isthmus. The incidence of an isthmus 3 mm from the apex was 89.3% and 100% in the MB roots of the maxillary first molars and in the M roots of the mandibular first molars, respectively. The mean dentin thickness between the isthmus and the distal root surface was <1 mm at a distance of 3 mm from the apex in both types of roots. In this study, whenever two main canals were located in the MB roots of the maxillary first molars and in the M roots of the mandibular first molars, the likelihood of the presence of an isthmus increased. Therefore, clinicians should be aware of the thinnest dimensions in the distal surface of the MB roots of the maxillary first molars and the M roots of the mandibular first molars during nonsurgical and surgical root canal treatment.

Effects of fast- and slow-setting calcium silicate-based root-end filling materials on the outcome of endodontic microsurgery: a retrospective study up to 6 years

OBJECTIVES

The purpose of this retrospective study was to evaluate and compare the effects of fast- and slow-setting calcium silicate-based materials (CSMs) used for root-end filling on the outcome of endodontic microsurgery.

MATERIALS AND METHODS

We searched a clinical database for patients who had received endodontic microsurgery between 2001 and 2016. Included cases were divided into two groups according to the type of CSM used for root-end filling: slow-setting CSM (SCSM) and fast-setting CSM (FCSM). The cases in two groups were subjected to 1:1 nearest neighbor propensity score matching for the following variables: age, sex, tooth type, quality of canal filling, lesion type, and postoperative restoration. For each matched case, the outcome was determined as success or failure according to clinical and radiographic evaluations performed at least 1 year after surgery. Multivariate logistic regression analysis was performed to identify prognostic factors and estimate their effects.

RESULTS

In total, 304 cases of endodontic microsurgery (179 SCSM and 125 FCSM) were identified, and 1:1 propensity score matching finally included 122 cases from each group. After matching, all covariates were associated with an absolute standardized difference of < 0.1. The overall success rates were 85.2% and 93.4% for the SCSM and FCSM groups, respectively (p = 0.062). Age, tooth type, lesion type, and CSM type were significantly associated with the outcome of endodontic microsurgery (p < 0.05).

CONCLUSIONS

Within the limitations, the outcome of endodontic microsurgery using FCSMs was comparable with that of SCSMs. The findings suggest that the type of CSM used for root-end filling, particularly in terms of the initial setting time, could affect the outcome of endodontic microsurgery.

CLINICAL RELEVANCE

FCSMs could be considered for use as root-end filling materials in endodontic microsurgery, particularly in complicated clinical situations which require rapid initial setting of the materials.

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.

An Insight into Histopathologic Examination as a Gold Standard for the Diagnosis of Chronic Apical Periodontitis

Objective: The purpose of our study was to determine the level of correlation between histopathologic results after surgery for chronic apical periodontitis and the radiographic and clinical diagnosis. The status of gold standard technique of histologic examination was evaluated in the diagnosis of apical radiolucency in necrotic teeth.

Methods: Out of 154 patients with incorrect root fillings and apical radiolucency included in an endodontic retreatment protocol, 87 patients (108 teeth) were scheduled for apical surgery at 3-6 months control recall. Clinical and radiographic exams were completed prior to surgery and compared to the histological results of apical biopsies. The collected data were statistically analyzed with the SPSS version 20.0 and the Chi-square test was used to determine the associations between clinical and histologic diagnosis. A value of p <0.05 was considered statistically significant.

Results: There was a statistically significant difference between the number of cases diagnosed as granulomas or cysts during clinical and radiological evaluation compared to histologic evaluation of tissue samples, with 40.9% to 75.9% and 54.2% to 16.8% respectively (p<0.05).

Conclusions: The final diagnosis was obtained only after histologic examination of apical tissue samples, which means that the observations made based on radiologic investigations must be confirmed by biopsy.

Clinical and Radiographic Outcomes of Apical Surgery: A Clinical Study

Background

Endodontic treatment is usually indicated when teeth with periapical lesions are encountered. However, sometimes root canal treatment results in failure. In that case, one of the treatment choices is retreatment by an orthograde approach. Surgical endodontic therapy is also an alternative to preserve the tooth. Various techniques have been suggested in the literature which has more predictable results. The introduction of modern surgical techniques have enhanced the results of apical surgery procedures. Operating microscopes, magnifying loupes, microinstruments, ultrasonic tips, and biologically acceptable root-end filling materials (such as MTA and SuperEBA) have been introduced to this field with the modern technique, thus the success rates of modern apical surgery has increased significantly.

Objective

The aim of the present study was to evaluate the clinical and radiographic outcomes and periotest values of apical surgery treatment.

Methods

A total of 112 teeth were included. SuperEBA and MTA were used as root-filling materials. The recorded parameters were gender, age, location of the tooth, the presence/absence of a post, coronal restoration of the tooth, previous surgical/nonsurgical treatment of the tooth, the size of periapical lesions, histopathology of periapical lesions, smoking habits. Also the periotest values were recorded.

Results

The overall success rate was 88.4%. With regard to the evaluated variables, only one parameter (tooth type) was found statistically significant. Although the periotest values were decreased after 6 months compared to immediately postoperative measurements, the values were still significantly higher than preoperative measurements.

Conclusion

In this study, apical surgery performed with the modern instruments has significantly successful results with 88.4% success rate.

Effect of novel chelating agents on the push-out bond strength of calcium silicate cements to the simulated root-end cavities

To compare the effects of different chelating agents on the push-out bond strength of calcium silicate-based cements to the simulated root-end cavities. Root-end cavities were prepared on the roots of fifty extracted maxillary anterior teeth. The specimens were then randomly divided into 5 groups (n = 10) based on the final irrigation regimen: Group 1: 17% EDTA, Group 2: 7% maleic acid, Group 3: QMix, Group 4: 2.25% peracetic acid (PAA), Group 5: 0.9% saline. Then, the samples from each group were subdivided into two groups (n = 5) based on the apical filling material. In group 1, root-end cavities of all samples were filled with Biodentine and in group 2, with MTA. Each sample was horizontally sectioned to produce two discs of ∼1 mm thick per specimen. The maximum load required for the dislodgement of 100 retrofillings was recorded. The specimens were examined under scanning electron microscope after debonding to assess the type of bond failure. Data were statistically analyzed using Kruskal Wallis and Mann Whitney U tests. Irrigation with saline resulted in higher bond strength compared to the other irrigants in the retrograde cavities obturated with MTA or Biodentine (p < .05). In MTA group, there was no significant difference between the test irrigants (p > .05). EDTA and PAA groups showed higher dislodgement resistance values than the other test irrigants, when Biodentine was used as a filling. The type of irrigation solution influences the bond strength of the root-end fillings.

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.

Mineral trioxide aggregate and other bioactive endodontic cements: an updated overview - part II: other clinical applications and complications

Mineral trioxide aggregate (MTA) is a dental material used extensively for vital pulp therapies (VPT), protecting scaffolds during regenerative endodontic procedures, apical barriers in teeth with necrotic pulps and open apices, perforation repairs as well as root canal filling and root-end filling during surgical endodontics. A number of bioactive endodontic cements (BECs) have recently been introduced to the market. Most of these materials have calcium and silicate in their compositions; however, bioactivity is a common property of these cements. These materials include the following: BioAggregate, Biodentine, BioRoot RCS, calcium-enriched mixture cement, Endo-CPM, Endocem, EndoSequence, EndoBinder, EndoSeal MTA, iRoot, MicroMega MTA, MTA Bio, MTA Fillapex, MTA Plus, Neo MTA Plus, Ortho MTA, Quick-Set, Retro MTA, Tech Biosealer, and TheraCal LC. It has been claimed that these materials have properties similar to those of MTA but without the drawbacks. In Part I of this review, the available information on the chemical composition of the materials listed above was reviewed and their applications for VPT was discussed. In this article, the clinical applications of MTA and other BECs will be reviewed for apexification, regenerative endodontics, perforation repair, root canal filling, root-end filling, restorative procedures, periodontal defects and treatment of vertical and horizontal root fractures. In addition, the literature regarding the possible drawbacks of these materials following their clinical applications is reviewed. These drawbacks include their discolouration potential, systemic effects and retreatability following use as a root filling material. Based on selected keywords, all publications were searched regarding the use of MTA as well as BECs for the relevant clinical applications. Numerous publications were found regarding the use of BECs for various endodontic applications. The majority of these investigations compared BECs with MTA. Despite promising results for some materials, the number of publications using BECs for various clinical applications was limited. Furthermore, most studies had several methodological shortcomings and low levels of evidence.

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.